×
Text Size: A- | A | A+

Marshall Browning Hospital

Notice of Privacy Practices


This notice describes how your medical information may be used and disclosed, and how you can access this information. Please review it carefully.

I. Who we are

This Notice describes the privacy practices of Marshall Browning Hospital. It also applies to independent health care providers while providing services in our facility, such as physicians who are not employed by us but who attend patients in our facility. This Notice; however, does not govern the privacy practices of these other health care providers for services they provide outside of our facility.

II. Our Privacy Obligations

We are required by law to: a) maintain the privacy of your individually identifiable health information Protected Health Information or ("PHI")*. We are also to: b) provide you with this notice of our legal duties and privacy practices with respect to your Protected Health Information. Lastly, when we use or disclose your PHI, we are required to: c) abide by the terms of our notice that is currently in effect.

Permissable Uses and Disclosure Without Your Written Authorization

The following describes the ways we may use and disclose your PHI without written authorization. Except for the purposes described below in (section II, A-P), we will use and disclose PHI only with your written permission. You may revoke such permission at any time by writing to our Privacy Officer.

A. Uses and Disclosures For Treatment, Payment and Health Care Operations. We may use and disclose PHI in order to treat you, obtain payment for services provided to you and conduct our "health care operations" as detailed below.

Treatment. We use and disclose your "PHI" to provide treatment and other services to you; for example, to diagnose and treat your injury or illness. In addition, we may contact you to provide appointment reminders or other health-related benefits and services that may be of interest to you. We may also disclose "PHI" to other providers involved in your treatment.

Payment. We may use and disclose your "PHI" to obtain payment for the services we provide to you, or to your healthcare providers who treated you to receive payment for services they rendered to you; for example, disclosures to obtain payment from Medicare, Medicaid, your health insurer, HMO, or other company or program that arranges or pays the cost of some or all of your health care. We may also use and disclose your information to a third party who provides collection services on behalf of Marshall Browning Hospital.

Health Care Operations. We may use and disclose your "PHI" for our health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you. For example, we may use "PHI" to evaluate the quality and competence of our physicians, nurses and other health care workers.

We may use and disclose your "PHI", such as your e-mail address, to contact you through a survey to ask your opinion about the quality of these services we provided to you. We may also disclose "PHI" in the course of other health care operations such as participating in medical, nursing, oro ther clinical training programs or education or conducting quality improvement activities, or for health care fraud and abuse detection or compliance.

B. Use or Disclosure for Directory of Individuals in Marshall Browning Hospital. We may include your name and/or location at our facility, general health condition and religious affiliation in a patient directory without obtaining your authorization unless you object to inclusion in the directory. Information in the directory may be disclosed to anyone who asks for you by name or members of the clergy; provided, however, that religious affiliation will only be disclosed to members of the clergy.

C. Disclosure to Relatives, Close Friends and Other Caregivers. We may use or disclose your "PHI" to a family member; other relative, a close personal friend or any other person identified by you when you are present for; or otherwise available prior to, the disclosure, if we (1) obtain your agreement; (2) provide you with the opportunity to object to the disclosure and you do not object; or (3) reasonably infer that you do not object to the disclosure.

If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interest. If we disclose information to a family member; other relative or a close personal friend, we would disclose only information that we believe is directly relevant to the person's involvement with your healthcare or payment related to your health care. We may also disclose your "PHI" in order to notify (or assist in notifying) such persons of your location, general condition or death.

D. Fundraising Communications. We may contact you to request a tax-deductible contribution to support important activities of Marshall Browning Hospital. In connection with any fundraising, we may only disclose to our fundraising staff demographic "PHI", information about you (e.g., your name, address, phone number, age and gender) and dates on which we provided health care to you, without your written authorization. You may choose to "opt-out" of this communication by contacting the Marketing Director.

E. Public Health Activities. We may disclose your "PHI" for the following public health activities: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to the Illinois Department of Children and Family Services or other government authorities authorized by law to receive such reports; (3) to report information about products and services under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance and (6) to report births and deaths.

F. Victims of Abuse, Neglect or Domestic Violence. If we reasonably believe you are a victim of abuse, neglect or domestic violence, we may disclose your "PHI" to the Illinois Department of Human Services or other governmental authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence.

G. Health Oversight Activities. We may disclose your "PHI" to a health oversight agency that oversees the health care facility and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.

H. Law Suits and Disputes. We may disclose your "PHI" in the course of a judicial or administrative proceeding in response to a legal court order, subpoena, discovery request or other lawful process.

I. Law Enforcement Officials. We may disclose your "PHI" to the police or other law enforcement official as required or permitted by law or in compliance with a court order, subpoena, warrant, summons or similar process.

J. Decedents. We may disclose your "PHI" to a coroner or medical examiner as authorized by law. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release PHI to funeral directors as necessary for their duties.

K. Organ and Tissue Procurement. We may disclose your "PHI" to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.

L. Research. Although Marshall Browning Hospital does not directly initiate or participate in research studies, patients and/or their physicians may be enrolled in research that requires access to the enrolled patient's PHI. We may release PHI for patients enrolled in a research study as directed by the participants.

M. Health or Safety. We may use or disclose your "PHI" to prevent or lessen a serious and imminent threat to a person's or the public's health or safety. Disclosures, however, will be made only to someone who may be able to help prevent the threat. Additionally, we may disclose your PHI to disaster relief organizations to help coordinate your care or notify family and friends of your location or condition; however, we will provide you with an opportunity to object to such a disclosure whenever we pratically can do so.

N. Specialized Government Functions. We may use and disclose your "PHI" to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.

O. Worker's Compensation. We may disclose your "PHI" as authorized by and to the extent necessary to comply with state law relating to worker's compensation or other similar programs. These programs provide benefits for work-related injuries or illnesses.

P. As required by law. We may use and disclose your "PHI" when required to do so by any other law not already referred to in the preceding categories.

Q. Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Health Information to the correctional institution or law enforcement official. This release would be if 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) the safety and security of the correctional institution.

R. Business Associates. We may disclose PHI to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

S. Data Breach Notification Purposes. We may use or disclose your PHI to provide legally required notices of unauthorized access to or disclosure of your health information.

T. Health Information Exchange. We may use and disclose your PHI without your consent or authorization to the Southern Illinois Health Information Exchange (SI HIE). A Health Information Exchange, or HIE, is a way of electronically sharing your health information to healthcare providers involved in your care. The purpose of the HIE is to give participating providers faster access to your health information that will facilitate safer, more timely, and efficient patient-centered care. For example, if you have an emergency visit at Marshall Browning Hospital that warrants imaging studies to be taken and you need follow up care with an SIH-associated physician, Marshall Browning Hospital can send your images through our PACS system to SIH.

If you do not want your health information maintained by Marshall Browning Hospital to be accessible to authorized health care providers through the HIE, you may opt out by completing or sending a non-participation (opt-out) form to the Privacy Officer. If you decide to opt-out of the HIE then doctors, nurses and other health care providers will not be able to obtain and use your health information in the HIE when providing treatment to you. For further information about SI HIE and/or to obtain an opt-out form, please contact the Privacy Officer of Marshall Browning Hospital (address provided at the end of this Notice).

IV. Uses and Disclosures Requiring Your Written Authorization

The following uses and disclosures of your Protected Health Information will be made only with your written authorization:

A. Marketing. We must also obtain your written authorization prior to using your PHI to send you any marketing materials. (We can, however, provide you with marketing materials in a face-to-face encounter without obtaining your marketing authorization. We are also permitted to give you a promotional gift of nominal value, if we so choose, without obtaining your marketing authorization). In addition, we may communicate with you about products or services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers or care settings without your marketing authorization.

B. Uses and Disclosures of Your Highly Confidential Information. In addition, federal and Illinois law requires special privacy protections for certain highly confidential information about you, including the subset of your PHI that: (1) is maintained in psychotherapy notes; (2) is about mental health and developmental disabilities sevices; (3) is about alcohol and drug abuse prevention, treatment and referral; (4) is about HIV/AIDS testing, diagnosis or treatment; (5) is about venereal disease(s); (6) is about genetic tetsting; (7) is about child abuse and neglect; (8) is about domestic abuse of an adult with a disability; or (9) is about sexual assault. In order for us to disclose your highly confidential information for a purpose other than those permitted by law, we must obtain your written authorization.

C. Disclosures that constitute a sale of your Protected Health Information.

D. Genetic testing. If in the future Marshall Browning Hospital should provide genetic testing services, MBH will require your written authorization prior to any disclosure to your health plan.

Other uses and disclosures of PHI not covered by this Notice or the laws that apply to us will be made only with your written authorization.

V. Your Rights Regarding Your Protected Health Information (PHI)

You have the following rights regarding Health Information we have about you:

A. For Further Information; Complaints. If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to your PHI, you may contact our Privacy Officer. You may also file complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Privacy Officer will provide you with the correct address for the Director. All complaints must be made in writing. We will not retaliate against you if you file a complaint.

B. Right to Request Additional Restrictions. You may make written requests for restrictions on our use and disclosure of your PHI, (1) for treatment, payment and health care operations, (2) to individuals (such as a family member; other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction. We are required to comply with request for a restriction involving a disclosure to (1) a health plan for purpose of carrying out payment or health operations; and (2) the PHI pertains solely to a healthcare items or service which has been fully paid out of the pocket. If you wish to request additional restrictions, please obtain a request form from our Privacy Officer and submit the completed form to the Privacy Officer.

We will send you a written response.

C. Right to Receive Confidential Communications. You may request, and we will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations.

D. Right to Revoke Your Authorization. You may revoke your Release of Information authorization, marketing authorization and fundraising authorization, or any written authorization, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Privacy Officer identified at the end of this Notice. A form of Written Revocation is available upon request from the Privacy Officer.

E. Right to Inspect and Copy Your Health Information. Upon written request, you may access your medical record file and billing records maintained by us in order to inspect and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records; however, you have the right to have the denial reviewed. To obtain a record request form, contact the Health Information Department at Marshall Browning Hospital. If you request copies in paper or electronic format, there may be a charge, if applicable; including, information that cannot routinely be copied or duplicated on a standard commercial photocopy machine, such as xray films or pictures. We may also charge you for our postage costs, if you request that we mail the copies to you. We have up to 30 days to make your PHI available to you.

F. Right to an Electronic Copy of Electronic Medical Records. If your PHI is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your PHI in the form of format you request, if it is readily producible in such form or format. If the PHI is not readily producible in the form or format you request, your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record as well as any physical media (e.g., computer disc) used to process your request.

G. Right to Amend Your Records. You have the right to request that we amend PHI maintained in your medical record file or billing records. If you desire to amend your records, obtain an amendment request form from the Director of Health Information and submit the completed form back to the Director of Health Information. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply. In the case of a requested amendment concerning information about the treatment of a mental illness or developmental disability, you have the right to appeal our decision not to amend your PHI to an Illinois court.

H. Right to Receive an Accounting of Disclosures. Upon written request to Health Information Services, you may obtain an accounting of certain disclosures of your PHI used for purposes other than treatment, payment and health care operations, made by us during any period of time prior to the date of your request provided such period does not exceed six years. If you request an accounting more than once during a twelve (12) month period, an estimate of the cost will be provided at the time of the additional requests.

I. Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured PHI.

J. Out-of-Pocket-Payments. If you paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your PHI with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.

K. Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice at any time (in the Admitting Office), even if you have agreed to receive such notice electronically. You may also obtain a copy of this notice at our web site, www.marshallbrowninghospital.com. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

VI. Effective Date and Duration of This Notice.


A. Effective date: This Notice is effective on September 9, 2013.

B. Right to Change Terms of this Notice. We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all PHI that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice in the Admitting Office and on our Internet site a www.marshallbrowninghospital.com.

You also may obtain any new notice by contacting the Privacy Officer or the Admitting Office.

VII. Privacy Officer

You may contact the Privacy Officer at:

Privacy Officer
Marshall Browning Hospital
P.O. Box 192
DuQuoin, IL 62832
Telephone Number: 618-542-1012

PHI is individually identifiable under HIPAA if it includes (but not limited to): your name, address, zip code, geographical codes, dates of birth, other elements of dates, telephone or fax numbers, email address, social security number, insurance information, medical record number, member or account number, certificate/license number, voice or finger prints, photos or any other unique identifying numbers, characteristics or codes of you.

Notice of Privacy Practices: Revision 09-23-13
All physicians and mid-level providers furnishing services are independent contractors and are not employees of Marshall Browning Hospital with the exception of Dr. Gladstone Tucker, Dr. Malcolm Schulz, Dr. E. Clay Travis, Danielle Klump, FNP, Ariele Loiacono, FNP, Elizabeth Harbison, FNP, Michael Staff, PA-C, Heather Rice, PA-C, and Heather Burns, RD/LDN, CDE. Emergency Room physician services are provided by Integritas Emergency Physician Services. Hospitalist services are provided by Integritas. Radiology services are provided under the auspices of Cape Radiology and pathology services are provided by SEMC Pathology. Specialty Clinics physicians holding clinics at Marshall Browning Hospital are independent contractors and are not employees of Marshall Browning Hospital. Anesthesia services are provided under the auspices of Southern Illinois Medical Services.
INDEPENDENT PHYSICIAN FEES ARE NOT ELIGIBLE FOR FINANCIAL ASSISTANCE:
Independent physicians providing services at Marshall Browning Hospital bill for their services separately and the Hospital Financial Assistance application does not cover nor apply to fees charged. Independent physicians include but are not limited to emergency room physicians (Integritas Emergency Physician Services), radiologists (Cape Radiology), anesthesia (Southern Illinois Medical Services),and pathologists (SEMC). All specialty clinic physicians also bill for their services separately and the Hospital Financial Assistance application does not cover nor apply to fees charged with the exception of the following physicians: Endocrinology Clinic: Issa Abed, M.D.; Gastroenterology Clinic: Christine Hachem, M.D., Alex Befeler, M.D.,Bruce Bacon, M.D., Jason Taylor, M.D.; Pain Management: Paul Juergens, M.D.; Pulmonology: Suhail Istanbouly, M.D.; Rheumatology: Frederick Pfalzgraf, M.D.; Sleep Clinic: Suhail Istanbouly, M.D.; Surgery & Wound Clinic: Malcolm A. Schulz, M.D.
MARSHALL BROWNING MEDICAL CLINIC:
Marshall Browning Medical Clinic and Marshall Browning Family Health Center are hospital-based rural health clinics operated under Marshall Browning Hospital. Eligibility for financial need assistance as determined through the Patient Financial Assistance application will apply to services billed through the Marshall Browning Medical Clinic and Family Health Center.