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TERRE HAUTE MEDICAL LABORATORY, INC.


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.

 Effective date: 04/14/03

If you have any questions about this notice, please contact our Compliance Department at (812) 232-9557, Ext. 143.

OUR PLEDGE REGARDING MEDICAL INFORMATION:

We are required by law to maintain the privacy of your health information and to provide you with notice of our legal duties and privacy practices. Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your medical information created in the doctor’s office or clinic.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU:

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

For Treatment.

  • We may use your medical information to provide you with treatment or services.
  • We may disclose your medical information to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you.
  • For Example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. Different departments may share medical information about you to people outside Terre Haute Medical Laboratory, Inc., who may be involved in your medical care after you leave.
For Payment.

  • We may use and disclose your medical information to bill and collect payment for treatment and services provided to you.
  • For example, we may give your health information to your insurance company about treatment you received so they will pay us or reimburse you. We may also tell your insurance about treatment you are going to receive to obtain prior approval or find out whether they will pay for treatment.
For Health Care Operations.
  • We may use and disclose medical information about you for our business operations. These uses and disclosures are necessary to run Terre Haute Medical Laboratory, Inc. and make sure that all of our patients receive quality care.
  • For example, we may use medical information to review our treatment and services and to evaluate our performance.
    • We may combine medical information about many patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective.
    • We may disclose information to doctors, nurses, technicians, medical students, and other personnel for review and learning purposes.
    • We may combine the medical information we have with medical information from other hospitals to compare how we are doing and see where we can make improvements in the care and services we offer.
    • We will remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.
THE FOLLOWING USES AND DISCLOSURES ARE REQUIRED BY LAW

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 and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Organ and Tissue Donation. If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue 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. We may also release medical information about foreign military personnel to the appropriate foreign military authority.

Workers’ Compensation. We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. We may disclose medical information about you for public health activities or similar programs. These programs provide benefits for work-related injuries or illness.
  • To prevent or control disease, injury or disability;
  • To report births and deaths
Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, 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. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute.

Law Enforcement. We may release medical information if asked to do so by a law enforcement official:

  • 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 limited circumstances, we are unable to obtain the person’s agreement;
  • About a death we believe may be the result of criminal conduct;
  • 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 release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of the hospital to funeral directors as necessary to carry out their duties.

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

Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

Inmates. An inmate does not have rights listed in this Notice of Privacy Practices. The rights listed in this notice will not apply to inmates of a correctional institution.

YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION

Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. This includes medical and billing records, but does not include psychotherapy notes.

  • To inspect and copy medical information that may be used to make decisions about you, you must submit your request to our Client Service Department at (812) 232-1392. If you request a copy of the information, we may charge a fee for the costs of copying or other supplies associated with your request. Test results must be picked up in person and a photo ID is required.
Right to Amend. If you feel that medical information we have about you is incorrect you have the right to request an amendment. To request an amendment, your request must be made in writing and submitted to the Compliance Department at (812) 232-9557, Ext 143. They will give you the appropriate form to complete which must include the reason for your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, 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 medical information kept by Terre Haute Medical Laboratory, Inc.
  • Is not part of the information which you would be permitted to inspect and copy; or
  • Is accurate and complete.
Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of people who you authorized to see your medical records. To request this list or accounting of disclosures, you must submit your request in writing to the Compliance Department. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on the ways medical information is used. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. We can, without your consent, terminate any restrictions or limitations we have previously agreed to without notice to you, but the termination of those restrictions will apply only to information obtained or acquired after that termination. To request restrictions, you must make your request in writing to the Compliance Department. In your request, you must tell us (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 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 request confidential communications, you must make your request in writing to the Compliance Department. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of this Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

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 in all Terre Haute Medical Laboratory, Inc. facilities. The notice will contain the effective date. In addition, each time you register for treatment or health care services, we will make a copy of the current notice available to you.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with Terre Haute Medical Laboratory, Inc. or with the Secretary of the Department of Health and Human Services. To file a complaint with Terre Haute Medical Laboratory, Inc., contact the Privacy Officer in the Compliance Department at. All complaints must be submitted in writing. Our Compliance Department is located at:

634 Beech St.
Terre Haute, IN 47808
(812) 232-9557, Ext 143

YOU WILL NOT BE PENALIZED FOR FILING A COMPLAINT.

OTHER USES OF MEDICAL INFORMATION

Other uses and disclosures of medical information not covered by this notice or law will be made only with your written permission. If you provide us permission to use or disclose medical information, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. Terre Haute Medical Laboratory, Inc. is 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.