Notice of Privacy Practices

Effective October 7, 2016

THIS NOTICE DESCRIBES HOW YOUR PROTECTED HEALTH INFORMATION MAY BE USED AND DISCLOSED, AND WHAT RIGHTS YOU MAY HAVE TO ACCESS YOUR PROTECTED HEALTH INFORMATION. PLEASE REVIEW IT CAREFULLY.

Goshen Hospital believes your health information is personal and is committed to protecting the privacy of the health information it creates or receives about you. Goshen Hospital has a professional and legal obligation to respect your confidentiality.
“Protected health information” is health information or other individually identifiable information such as demographic data, that may identify you. Protected health information is information about your past, present or future physical or mental health or condition related to healthcare services.
This Notice of Privacy Practices describes how Goshen Hospital may use and disclose your protected health information to carry out treatment, for payment, for healthcare operations and for other purposes permitted or required by law. This Notice also describes certain rights that you may have to access your protected health information. Goshen Hospital is required to abide by the terms of this Notice of Privacy Practices.
The terms of this Notice may change at any time. The new Notice will apply to all protected health information acquired after it goes into effect. Upon your request, Goshen Hospital will provide you with any historical Notice of Privacy Practices or you may obtain the most current copy by visiting the Goshen Hospital website at www.GoshenHealth.com/Privacy.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION THAT DO NOT REQUIRE YOUR AUTHORIZATION

Your protected health information may be used and disclosed by those involved in your care and treatment for the purpose of providing healthcare services to you. Your protected health information may also be used and disclosed to obtain payment for services rendered and to support the operations of Goshen Hospital. The following list, by way of example rather than limitation, explains certain uses and disclosures of your protected health information that Goshen Hospital is permitted to make.

TREATMENT

Goshen Hospital will use and disclose your protected health information to provide, coordinate or manage your healthcare and any related services. This includes the coordination or management of your healthcare with another provider. For example, Goshen Hospital may disclose your protected health information, as minimally necessary, to a home health agency that provides care to you.
Goshen Hospital will also disclose health information to physicians or other healthcare providers who may be treating you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to treat you.
In addition, Goshen Hospital may disclose your protected health information from time-to-time to another physician or healthcare provider (e.g., specialist or laboratory) who, at the request of your physician becomes involved in your care by providing assistance with your healthcare diagnosis or treatment. As another example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process.

Goshen Hospital participates in certain Health Information Exchanges or Organizations (HIEs or HIOs). For example, Goshen Hospital participates in the Indiana Health Information Exchange (IHIE) and Indiana Network for Patient Care (INPC), which helps to make your protected health information available to other healthcare providers who may need access to it in order to provide care or treatment to you.

PAYMENT

Goshen Hospital may use and disclose your protected health information as necessary to obtain payment for healthcare services. For example: (1) to make a determination of eligibility or coverage for insurance benefits, (2) review services provided to you for medical necessity and to undertake utilization-review activities and (3) approve or pay for recommended healthcare.

HEALTHCARE OPERATIONS

Goshen Hospital may use or disclose your protected health information in order to support our business activities. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. Goshen Hospital may share your protected health information with “business associates” or third-party organizations which perform services such as billing or transcription services on behalf of Goshen Hospital. Goshen Hospital has written contracts with its business associates to protect the privacy of your protected health information, and business associates are also required by law to comply with the same privacy and security requirements that apply to Goshen Hospital.

Goshen Hospital may use and disclose your protected health information to tell you about appointments and other matters related to your care. We may contact you by mail, telephone or e-mail. We may leave voice messages at the telephone number you provide to us, and we may respond to your emails.

Goshen Hospital may use and disclose your protected health information to tell you about possible treatment options, new services or alternatives that may be relevant to your healthcare.

FUNDRAISING ACTIVITIES

Goshen Hospital may use protected health information to contact you in an effort to raise money for its operations. It may disclose protected health information to a foundation related to Goshen Hospital so that it may raise money to support Goshen Hospital; you may request, in writing, not to be contacted for this purpose.

HOSPITAL DIRECTORY

Goshen Hospital may include limited information about you in the hospital directory while you are a patient. This information may include your name, location in the hospital and your general condition (e.g., fair or stable). This directory information may be released to people who ask for you by name so that they may generally know how you are doing. If you do not want this information shared, please let us know. Also, your religious affiliation may be given to a member of the clergy even if they do not ask for you by name.

INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE

Unless you indicate otherwise, Goshen Hospital may disclose to a relative, a close friend or other person you identify, a portion of your protected health information which directly relates to your healthcare. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary for your healthcare, if, based on our professional judgment, we determine that it is in your best interest. We may disclose protected health information to notify or assist in notifying a family member or personal representative (or any other person who is responsible for your care) of your location, general condition or death. Finally, we may disclose your protected health information to an authorized public or private entity to assist in disaster-relief efforts.

RESEARCH

Goshen Hospital performs medical research. Goshen Hospital may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure, among other things, the privacy of protected health information. Goshen Hospital may release information about you to researchers who need to know how many patients have a specific health issue in preparation for proposed research. If a doctor caring for you believes you may be interested in, or may benefit from, a research study, your physician and the research review committee will designate someone to contact you. This individual will see if you are interested in the study, provide you with more information and give you the opportunity to participate or to decline further contact.

TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY

Goshen Hospital may use and disclose protected health information about you when necessary to prevent a serious threat to your health and safety, or the health and safety of another person or the public. However, any disclosure would only be to someone who is able to help prevent the threat.

ORGAN AND TISSUE DONATION

Goshen Hospital may release protected health information to organizations that handle organ procurement or organ, eye or tissue transplantation, or to an organ-donation bank as minimally necessary to facilitate organ or tissue donation and transplantation.

WORKERS’ COMPENSATION

Goshen Hospital may release protected health information about you for workers’ compensation or similar programs that provide benefits for work-related injuries or illnesses.

PUBLIC HEALTH RISKS AND PATIENT SAFETY ISSUES

Goshen Hospital may disclose protected health information to a public health authority that is permitted by law to receive the information for public health activities. For example, disclosures may be made for the purposes of preventing or controlling disease, injury or disability; to report births and deaths; to report reactions to medications or problems with products; and to notify people of recalls of products that they may be using.

COMMUNICABLE DISEASES

Goshen Hospital may disclose or use your protected health information 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, and to comply with state-mandatory disease reporting, such as cancer registries.

ABUSE OR NEGLECT

Goshen Hospital may disclose your protected health information to a public health authority authorized by law to receive reports of child abuse or neglect, and to notify the appropriate government authority if Goshen Hospital believes a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure as required or authorized by law.

HEALTH OVERSIGHT ACTIVITIES

Goshen Hospital may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections and licensure. These activities are necessary for the government to monitor the healthcare system, government benefit programs and compliance with civil-rights laws.

FOOD AND DRUG ADMINISTRATION(FDA)

Goshen Hospital may disclose your protected health information to a person or company required by the Food and Drug Administration for the purpose of managing the quality, safety or effectiveness of FDA-regulated products or activities, which include: reporting adverse events, product defects or problems, biologic product deviations; tracking products; enabling product recalls; making repairs or replacements; or to conduct post-marketing surveillance, as required.

LEGAL PROCEEDINGS

Goshen Hospital may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized) or in certain conditions in response to a subpoena, discovery request or other lawful process.

LAW ENFORCEMENT

Goshen Hospital may disclose protected health information for certain law-enforcement purposes, such as: 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; about criminal conduct at the hospital; and, 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

Goshen Hospital may release protected health information to a coroner or medical examiner, for example, to identify a deceased person or determine the cause of death. We may also release protected health information about patients of the hospital to funeral directors as necessary to carry out their duties.

MILITARY ACTIVITY AND NATIONAL SECURITY

Goshen Hospital may use or disclose the protected health information of individuals who are Armed Forces personnel for activities deemed necessary by appropriate military-command authorities, for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits or to foreign military authority if you are a member of that foreign military service. Protected health information may also be disclosed to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the president or others legally authorized.

INMATES

If you are an inmate of a correctional institution or under the custody of a law enforcement official, Goshen Hospital may release protected health information about you to the correctional institution or law enforcement official. This release would be necessary for the institution to provide you with healthcare, to protect your health and safety or the health and safety of others or for the safety and security of the correctional institution.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION THAT DO REQUIRE YOUR AUTHORIZATION

As described above, Goshen Hospital may use or disclose your protected health information to third parties for treatment, payment, healthcare operations and when permitted or required by law. Goshen Hospital will not disclose your protected health information for marketing purposes or the sale of protected health information. In addition, certain disclosures of your psychotherapy notes, mental health records and drug and alcohol abuse treatment records may require your prior written authorization.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION 

RIGHT TO INSPECT AND COPY

You have the right to inspect and obtain an electronic or paper copy of your protected health information that may be used to make decisions about your care. This includes medical and billing records, but may not include psychotherapy notes. To inspect and obtain a copy of your protected health information, you must submit your request in writing to the Goshen Hospital Health Information Management department. If you request a copy of the information, Goshen Hospital may charge a fee for the cost of copying, mailing or other supplies associated with your request.

Goshen Hospital may deny your request to inspect and copy records in some limited circumstances. If you are denied access to protected health information, you may request that the denial be reviewed. Another licensed healthcare professional chosen by Goshen Hospital will review your request and the denial. The person conducting the review will not be the person who denied your request. Goshen Hospital will comply with the outcome of the review.

RIGHT TO AMEND

You have a right to request an amendment of the health information that Goshen Hospital has in our records. Your request for an amendment must be made in writing, including a reason for the request and submitted to the Goshen Hospital Performance Improvement department. Goshen Hospital may deny a request for an amendment if it is not in writing and does not include a reason to support the request or requests for amendment of information that: was not created by Goshen Hospital; is not part of the protected health information kept by Goshen Hospital; is not part of the information which you would be permitted to inspect and copy; or is accurate and complete.

RIGHT TO RECEIVE NOTIFICATION

Individuals will receive notifications of their unsecured protected health information that is breached.

RIGHT TO AN ACCOUNTING OF DISCLOSURES

You have the right to request an accounting of disclosures. This is a list of disclosures Goshen Hospital has made of your protected health information, excluding disclosures for treatment, payment, healthcare operations or disclosures you authorized in writing. To request an accounting of disclosures, submit your request in writing and include the specific time period to Goshen Hospital Health Information Management department. Goshen Hospital will not list disclosures made earlier than six years before your request.

The first accounting of disclosure in a 12-month period is free. Additional accounting of disclosures may cost a fee; you will be notified in advance of any cost involved so that you may choose to withdraw or modify your request before incurring a cost.

RIGHT TO REQUEST RESTRICTIONS

You have the right to request a restriction on the ways your protected health information is used or disclosed. To request a restriction, submit your request in writing to the Goshen Hospital Privacy Counsel office. The request should include what information you want to limit, whether you want to limit use or disclosure, or both, and to whom you want the limits to apply – for example, disclosures to your spouse. Goshen Hospital is not required to agree to your request. If we do agree, we will comply with your restriction unless the information is needed to provide emergency medical treatment.

Goshen Hospital will agree to restrict disclosures of your health information to your health insurance plan for payment and healthcare operations purposes (not for treatment) if the disclosure pertains solely to a healthcare item or service for which you paid in full.

RIGHT TO REQUEST CONFIDENTIAL COMMUNICATION

You have the right to request that Goshen Hospital communicate with you about healthcare matters in a certain way or at a certain location. For example, you can request that you are only contacted at work or at a specific address. Such requests should be made in writing to the Goshen Hospital Performance Improvement department and should specify how or where you wish to be contacted. Goshen Hospital will accommodate all reasonable requests.


RIGHT TO A PAPER COPY OF THIS NOTICE

You have the right to a paper copy of this Notice of Privacy Practices, even if you have agreed to receive this Notice electronically. You may also find a copy of this Notice on the Goshen Health website, at www.GoshenHealth.com/Privacy.

OTHER USES OF PROTECTED HEALTH INFORMATION

Other uses and disclosures of your protected health information not covered by this Notice or allowed by law will be made only with your written permission. If you provide permission to use or disclose protected health information, you may revoke that permission, in writing, at any time. If you revoke your permission, Goshen Hospital will no longer use or disclose protected health information about you for the reasons covered by your written authorization. Goshen Hospital is unable to take back any disclosures it may have already made with your permission.

CHANGES TO THIS PRIVACY NOTICE

Goshen Hospital reserves the right to change this Notice and to make the revised or changed Notice effective for protected health information we already have about you, as well as any information we receive in the future. The revised Notice of Privacy Practices will be posted on our website at www.GoshenHealth.com/Privacy; you may also request that a revised or historical copy be sent to you in the mail or obtain one at the

QUESTIONS OR COMPLAINTS

If you believe Goshen Hospital has violated your privacy rights, you may file a complaint with Goshen Hospital Privacy Counsel office or with the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint. To file a complaint with Goshen Hospital, please submit a complaint in writing to the Goshen Hospital Performance Improvement department.

If you have further questions about this Notice of Privacy Practices, please contact the Goshen Hospital Privacy Officer as follow:

Alan Weldy
General Counsel/VP of HR/Compliance

Goshen Hospital
200 High Park Ave.
Goshen, IN 46526
(574) 364-2898
aweldy@goshenhealth.com

CONTACT INFORMATION

Department Release of Information
200 High Park Ave.
Goshen, IN 46526.
Telephone: (574) 364-1074

Goshen Hospital Privacy Officer
Goshen Hospital
200 High Park Ave.
Goshen, IN 46526
Telephone: (574) 364-2898

Goshen Hospital Marketing
Goshen Hospital
200 High Park Ave.
Goshen, IN 46526
Telephone: (574) 364-2915

Goshen Hospital Performance Improvement Department
Goshen Hospital
200 High Park Ave.
Goshen, IN 46526
Telephone: (574) 364-2729

Office for Civil Rights
U.S. Department of Health and Human Services
233 N. Michigan Ave., Suite 240
Chicago, IL 60601
dhhs.gov

Goshen Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.

ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call 1 (574) 364-1000 (TTY: 711 or 1 (800) 743-3333 to be connected with Relay Indiana).