Privacy Notice

Effective Date: April 14, 2003

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.

If you should have any questions about this Notice, please contact:

MCHD’s Privacy Officer at (979) 241-5550

or

visit our web site at http://matagordaregional.org.

WHO WILL FOLLOW THIS NOTICE?

Matagorda Regional Medical Center
104 7th Street
Bay City, Texas 77414

Matagorda County Public Health Clinic
1100 Avenue G
Bay City, Texas 77414

Matagorda Regional Medical Center Rehabilitation Services
2821 7th Street
Bay City, Texas 77414

All medical staff, including physicians with privileges¹ to provide health care services to patients of Matagorda Regional Medical Center and associated clinics.

Matagorda County Hospital District (MCHD), Matagorda Regional Medical Center, each clinic listed above, and the MCHD medical staff, will be part of an Organized Health Care Arrangement (“OHCA”) and are presenting you with this joint Notice. The OHCA allows each to share medical information about you for the purpose of treatment, payment, and healthcare operations.

We understand that medical information about you and your health is personal and we are committed to protecting this information. Each time you visit MCHD, we create a record of the care and services you receive. Typically, this record contains your symptoms, examinations and test results, diagnosis, treatment, and plan for future care or treatment. 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, and to your medical information (“Protected Health Information”) in the records, of your care generated by MCHD whether made by healthcare personnel, agents of the MCHD or your physician.

This Notice will tell you about the ways in which we may use and disclose health information about you. It also describes your rights and certain obligations we have regarding the use and disclosure of your medical information.

OUR RESPONSIBILITIES

MCHD will:

• Make every effort to maintain the privacy of your medical information;
• Provide you this Notice which describes our legal duties and privacy practices with respect to medical information we collect and maintain about you;
• Abide by the terms of this notice;
• Notify you if we are unable to agree to a requested restriction; and
• Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

THE METHODS IN WHICH WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

The following categories describe examples of the way we use and disclose medical information

For Treatment
We may use medical information about you to provide you with medical treatment and services. We may disclose medical information about you to doctors, nurses, technicians, medical students, interns, or other personnel who are involved in taking care of you during your visit with us. For example, a physician treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. Different departments of the MCHD also may share medical information about you in order to coordinate the different things you may need, such as prescriptions, lab work, meals, and x-rays. We may also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him/her in treating you once you are discharged from the hospital.

For Payment
We may use and disclose medical information about you so the treatment and services you receive at our health care facilities may be billed to and payment collected from you, an insurance company or a third party. For example, we may need to give your insurance company information about your surgery so that they will pay us or reimburse you for the treatment. We may also disclose medical information to your health plan to obtain prior authorization for treatment and procedures.

For Health Care Operations
We may use and disclose your medical information to perform general administrative functions and business planning and development necessary to operate the MCHD, including quality assurance activities where we assess the care and outcomes in your case. The result will be used to improve the quality of care for all patients served by MCHD. We may, for example, combine medical information about many patients to evaluate the need for new services or treatment.

We may remove information that identifies you from this set of medical information to protect your privacy. We may also use and disclose your medical information:

• To assess your satisfaction with our services
• To individuals involved in the payment of your care
• To tell you about possible treatment alternatives
• To tell you about health-related benefits of services
• To contact you as part of fundraising efforts
• To inform funeral directors, consistent with state law
• To health oversight agencies
• For population based activities relating to improving health or reducing health care costs
• For conducting training programs or reviewing competence of healthcare professionals
• To health plans for your plan to conduct quality review and assessment of our services.

These uses and disclosures are necessary to operate our health care facility and make sure all of our patients receive quality care.

To Business Associates for Treatment/Payment and Health Care Operations
There are some services provided in our organization through contracts with business associates. Examples of business associates include accreditation agencies, management consultants, attorneys, physician services in the emergency department, quality assurance reviewers, etc. When these services are contracted, we may disclose your medical information to our business associates so that they can perform the job we have asked them to do. To protect your medical information, we require our business associates to sign a contract that states they will appropriately safeguard your information.

Appointment Reminders
We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at our health care facility.

Future Communications
We may communicate to you via newsletters, mail-outs, or other means regarding treatment options, health-related information, disease-management programs, wellness programs, or other community-based initiatives or activities the MCHD is participating in.

Organized Health Care Arrangement
Our Organized Health Care Arrangement will share your medical information as necessary to carry out treatment, payment, and health care operations. Physicians and caregivers may have access to assist in reviewing past treatment as it may affect treatment at the time.

Research Unrelated to Treatment
When a research study does not involve any treatment, we may disclose your medical information to researchers when an Institutional Review Board (IRB) has reviewed the research proposal, has established appropriate protocols to ensure the privacy of your medical information, and has approved the research.

WITH YOUR SPECIFIC WRITTEN “AUTHORIZATION”

Directory Information
MCHD has a “directory” of information about hospitalized patients available to anyone who asks for a patient by name, and to the clergy that serve your religious affiliation. The directory information includes three items: 1) the patient’s name, 2) room number, 3) available to clergypersons only, religious affiliation. Your general condition (Undetermined, Good, Fair, Serious, Critical) may also be provided by a nurse or physician. You will be asked to agree to have this information disclosed each time you come to MCHD. You have the right to refuse to have all or part of your information disclosed for such purposes. If you do refuse to have all your information released, we will not be able to tell your family or friends your room number or that you are in the hospital. The purpose of the Patient Directory is to allow your family, friends and clergy to visit you at the Hospital and know how you are doing.

If you cannot provide your objection to these uses and disclosures because of incapacity or an emergency treatment circumstance, we may use or disclose some or all of this information if that disclosure is consistent with what you have told us previously and if the disclosure is in your best interest as determined in the exercise of our professional judgment.

Individuals Involved in Care/Payment
With your consent we may disclose medical information about you to a friend or family member who is involved in your medical care, unless you tell us in advance not to do so. Other uses and disclosures of medical information not covered by this notice or state and federal laws require us to make disclosures only with your written permission (called “authorization”). If you authorize us to use or disclose medical information about you, you may revoke that authorization in writing at any time. If you revoke your authorization, 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. Some typical disclosures that require your authorization are as follows:

Research Involving Treatment
When a research study involves your treatment, we may disclose your medical information to researchers only after you have signed a specific written authorization. In addition, for any such research study, an Institutional Review Board (IRB) will already have reviewed the research proposal, established appropriate protocols to ensure the privacy of your medical information, and approved the research. You do not have to sign the authorization in order to get treatment from MCHD, but if you do refuse to sign the authorization, you cannot be part of the research study.

Drug & Alcohol Abuse
Alcohol and drug abuse information has special privacy protections. MCHD will not disclose or provide any PHI relating to the patient’s substance abuse treatment unless: (1) there is a patient authorization; (2) a court order requires disclosure of the information; (3) medical personnel need the information to meet a medical emergency; (4) qualified personnel use the information for the purpose of conducting scientific research, management audits, financial audits or program evaluation; or (5) it is necessary to report a crime or a threat to commit a crime, or to report abuse or neglect as required by law.

Disclosure of Mental Health Information
We will disclose mental health treatment information about you only in accordance with state law. In most cases, state law requires your written authorization or the written authorization of your legally authorized representative for such disclosures.

Marketing or Fundraising
We may contact you, as authorized by state and federal law, as part of a marketing and/or fundraising effort. As part of our marketing, we may tell you about MCHD’s health-related products and services that may be of interest to you. If you receive a communication from us for either marketing or fundraising purposes, in most cases you will be told how you can opt out of any further marketing or fundraising activities.

SPECIAL SITUATIONS WHERE WE ARE REQUIRED TO USE OR DISCLOSE YOUR MEDICAL INFORMATION WITHOUT YOUR CONSENT OR AUTHORIZATION

The following disclosures of your medical information are permitted by law without any oral or written permission from you:

Organ and Tissue Donation
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.

Workers’ Compensation
We may release health information about you for worker’s compensation or similar programs if you have a work related injury. These programs provide benefits for work related injuries.

Disaster Relief
We may disclose medical information about you to an entity assisting in a disaster relief effort (such as the Red Cross) so that your family can be notified about your condition, status and location.

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 or safety or the health and safety of another person or the public. These disclosures would be made only to medical or law enforcement personnel able to help prevent the threat.

Public Health Activities
We may disclose medical information about you for public health activities. These 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, problems with products or other adverse events.
• 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 (including elder 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 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, or subpoena. We may disclose medical information about you in response to a subpoena, discovery request or other court ordered process to someone else involved in the dispute. We would only disclose this information if you have authorized the disclosure or a court has ordered us to do so.

Law Enforcement
We may disclose medical information if asked to do so by law enforcement officials for the following reasons:

• 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 circumstances, we are unable to obtain the victim’s agreement.
• About a death we believe may be the result of a criminal conduct.
• About criminal conduct at our facility.
• 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 disclose medical information to a coroner or medical examiner as authorized by law. This may be necessary to identify a deceased person or determine the cause of death of a person. We may also release medical information about patients at our facility to funeral home directors as necessary to carry out their duties.

National Security and Intelligence Activities
We may disclose medical information about you to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.

Inmates
If you are an inmate of a correctional institution or under the custody of a law enforcement official we may disclose medical information about you to the correctional institution or law enforcement official under specific circumstances such as (1) for the correctional 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.

Required By Law
We will disclose medical information about you without your permission when required to do so by federal or state law or regulation.

YOUR MEDICAL INFORMATION RIGHTS
Although your medical record is the physical property of MCHD, the information belongs to you. You have the right to:

1. Request Restrictions - Request a restriction on certain uses and disclosures of your information. We are not required by law to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
2. Copy - Obtain a paper copy of this Notice of Privacy Practices upon request.
3. Inspect - Inspect and/or request a copy of your medical record for a fee. Psychotherapy notes may not be inspected or copied. We may deny your request under very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed by another health care professional chosen by someone on our health care team who was not involved in your treatment or the denial of access to your medical information. We will abide by the outcome of that review.
4. Amend - Request an amendment to your medical record if you feel the information is incorrect or incomplete. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. Also, we may deny your request if the information was not created by our health care team, is not part of the information kept by our facility, is not part of the information which you would be permitted to inspect and copy, and if the information is accurate and complete. Please note that even if we accept your request, we are not required to delete any information from your medical record. We will attach documentation of the amendment to your record. MCHD will notify you in writing whether we agree or do not agree with your amendment request.
5. Accounting - Obtain an accounting of disclosures of your medical information. The accounting will only provide information about disclosures made for purposes other than treatment, payment or health care operations, or disclosures made without a properly executed authorization signed by you or your legally authorized representative. Requests for accountings must be in writing, and must state a time period, may not be longer than six (6) years, and may not include dates before April 14, 2003. The first list you request within a (12) twelve month period will be free of charge. For additional lists, we will charge you for the costs of providing the list. We will also notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
6. Confidential Communications - Request communication of your medical information by alternative means or locations.
7. Revocation - Revoke your consent or authorization to use or disclose medical information except to the extent that action has already been taken in reliance on the consent/authorization.
8. Complaint - If you believe that your privacy rights have been violated, you can submit a written complaint to us and request an investigation. Your complaint should be sent to:

MCHD Privacy Officer
104 7th Street
Bay City, Texas 77414
(979) 241-5550

You can also make a complaint to the Dept. of Health and Human Services by addressing your written complaint to:
Region VI, Office of Civil Rights
U.S. Department of Health and Human Services
1301 Young Street, Suite 1169
Dallas, Texas 75202

Your complaint must be filed within 180 days of when you knew or should have known that the act occurred.

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 on MCHD premises, and on MCHD’s web site. In addition, each time you register at, or are admitted to, MCHD for treatment or health care services as an inpatient or outpatient, you may request a copy of the current notice in effect.