Notice of Privacy Practices

Each of our facilities listed below is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about the privacy practices at any of our facilities please contact:

Each of the facilities of Union General Hospital, Inc. collects health information from you and stores it in a chart and on a computer. This is your medical record. The medical record is the property of Union General Hospital, Inc., but the information in the medical record belongs to you. We are required to protect the privacy of your health information. The law permits us to use or disclose your health information for the following purposes:

1. Treatment. We may use your health information to provide medical treatment or services to you. We may disclose health information about you to doctors, nurses, technicians, medical, nursing or other health care students, or other personnel taking care of you. For example, a physician treating you for an injury may need to know if you have diabetes because diabetes may complicate the healing process. In addition, the physician may need to tell the dietitian if you have diabetes so you can have appropriate meals. Various departments within our facilities may share your health information to schedule the tests and procedures you need, such as medications, laboratory tests, x-rays and therapies. We may also disclose your health information to other health care providers if you need to be transferred from one our facilities to another hospital, a nursing home, a rehabilitation center or a home health provider. We also may disclose your health information to other people who are involved in your care after you leave the one our facilities, such as family members or pharmacists.

2. Payment. We may use and disclose your health information so that the treatment and services you receive can be billed and payment collected from you, your insurance company or another third-party payor. For example, to receive payment for our services it may be necessary to disclose your health information to your health insurance plan. We also may tell your health insurance plan about a treatment you are going to receive in order to obtain prior approval from your plan to cover payment for the treatment. If you restrict us from providing your health information to your insurance plan, you will still be responsible for payment for our services.

3. Regular Health Care Operations. We may use or disclose your health information in order to perform our necessary administrative, educational, quality assurance, and business functions. For example, we may use your health information to evaluate the performance of our staff in caring for you. We also may use your health information to evaluate whether certain treatment or services offered by our facilities are effective. We also may disclose your health information to other physicians, nurses, technicians, or health profession students for teaching and learning purposes.

We may disclose information to other health care providers involved in your treatment to permit them to carry out the work of their facility or to get paid. For example, we may provide information about your treatment to an ambulance company that brought you one of our facilities so that the ambulance company can get paid for their services. We may combine health information about many patients to decide what services our facilities should offer, and whether new services are cost-effective and how we compare with other similar organizations. Sometimes, we may remove identifying information from this health information so others may use it to study health care data without learning who you are.

4. Patient and Resident Listings. We may list your name, where you are located in our facilities, your general medical condition and your religious affiliation in our patient and resident listings. This information may be provided to members of the clergy. This information, except your religious affiliation, may be provided to other people who ask for you by name. If you do not want us to list this information in our listings and provide it to clergy and others, you must tell us that you object. Your name may also be listed on or adjacent to the door of your patient room or resident room. This is done so to assist your family and friends with finding your location. If you do not want your name listed this way, you must tell us that you object.

Family Members and Friends. We may disclose your health information to individuals, such as family members and friends, who are involved in your care or who help pay for your care. We may make such disclosures when:

• we have your verbal agreement to do so;

• we make such disclosures and you do not object; or

• we can infer from the circumstances that you would not object to such disclosures.

For example, if your spouse comes into the exam room with you, we will assume that you agree to our disclosure of your health information while your spouse is present in the room.

We also may disclose your health information to family members or friends in instances when you are unable to agree or object to such disclosures, provided that we feel it is in your best interests to make such disclosures and the disclosures relate to that family member or friend’s involvement in your care. For example, if you arrive at one our facilities with an emergency medical condition, we may share information with the family member or friend that comes with you to our clinic.

7. Required by law. We may disclose your health information when required by federal, state, or local law to do so. For example, we are required by the Department of Health and Human Services (DHHS) to disclose your health information in order to allow DHHS to evaluate whether we are in compliance with the federal privacy regulations.

8. Public health. As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child or elder abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure.

9. Health oversight activities. We may disclose your health information to health agencies during the course of audits, investigations, inspections, licensure and other proceedings.

10. Judicial and administrative proceedings. We may disclose your health information in the course of any administrative or judicial proceeding.

11. Law enforcement. We may disclose your health information to a law enforcement official for purposes such as identifying of locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena and other law enforcement purposes.

12. Deceased person information. We may disclose your health information to coroners, medical examiners and funeral directors.

13. Organ donation. We will disclose your health information to organizations involved in procuring, banking or transplanting organs and tissues.

14. Research. We may use or disclose your health information for research purposes under certain limited circumstances. Because all research projects are subject to a special approval process, we will not use or disclose your health information for research purposes until the particular research project for which your health information may be used or disclosed has been approved through this special approval process. However, we may use or disclose your health information to individuals preparing to conduct the research project in order to assist them in identifying patients with specific health care needs who may qualify to participate in the research project. Any use or disclosure of your health information that is done for the purpose of identifying qualified participants will be conducted onsite at our facility. In most instances, we will ask for your specific permission to use or disclose your health information if the researcher will have access to your name, address, or other identifying information.

15. Public safety. We may disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.

16. Specialized Government Functions. We may disclose your health information for military or national security purposes. We may also disclose your health information, subject to state law, if you are an inmate of a correctional institution or under custody of a law enforcement official.

17. Worker’s compensation. We may disclose your health information as necessary to comply with worker’s compensation laws.

18. Marketing. We may contact you to give you information about other treatments or health-related benefits and services that may be of interest to you.

19. Fund-raising. We may contact you to participate in fund-raising activities for one or more of our facilities.

20. Change of Ownership. In the event that Union General Hospital, Inc. or one of its facilities is sold or merged with another organization, your health information/record will become the property of the new owner.

Except as described in this Notice of Privacy Practices, we will not use or disclose your health information without your written authorization. If you do authorize us to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.

1. You have the right to request restrictions on certain uses and disclosures of your health information. However, we are not required to agree to the restriction that you requested.

2. You have the right to receive your health information through a reasonable alternative means or at an alternative location. For example, you may specify a phone number where we can contact you regarding the results of a diagnostic test.

3. You have the right to inspect and copy your health information.

4. You have a right to request that we amend your health information that you believe is incorrect or incomplete. However, we are not required to change your health information and will provide you with information about our denial and how you can disagree with the denial.

5. You have a right to receive an accounting of disclosures of your health information made by any of our facilities, except that we do not have to account for the disclosures described in the Treatment, Payment, Regular Health Care Operations, Patient and Resident Listings and Specialized Government Functions of Section I of this Notice of Privacy Practices.

6. You have a right to a paper copy of this Notice of Privacy Practices.

If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, you should contact the Privacy Officer for the facility listed on page 1 of this Notice of Privacy Practices.

Union General Hospital, Inc. reserves the right to amend this Notice of Privacy Practices at any time in the future, and to make the new provisions effective for all information that it maintains, including information that was created or received prior to the date of such amendment. Until such amendment is made, we are required by law to comply with this Notice.

The revised Notice of Privacy Practices will be posted in one or more public locations in our facilities and will be distributed to our patients and residents when it becomes effective.

Complaints about this Notice of Privacy Practices or how we handle your health information should be directed to the Privacy Officer for the facility listed on page 1 of this Notice of Privacy Practices.

If you are not satisfied with the manner in which we handle a complaint, you may submit a formal complaint to the Department of Health and Human Services, Office of Civil Rights. You may also address your complaint to one of the regional Offices for Civil Rights. A list of these offices can be found online at http://www.hhs.gov/ocr/regmail.html.

Effective April 14, 2003