Notice of Privacy Practices

Effective April 14, 2003

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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.

Who We Are

This Notice describes the privacy practices of Methodist Medical Center of Illinois, Methodist Health Services Corporation and the members of its medical staff, nurses, volunteers, and other personnel ("Methodist," "we" or "us"). It also applies to all business associates with whom we may share information. It applies to your medical information, including your medical record, for all services provided to you in our clinically integrated care setting at the hospital, Methodist MedPointes and other Methodist physician offices and clinics.

We understand that your medical information is confidential and we are committed to maintaining its privacy. Federal law requires that we provide you with this Notice of our legal duties and privacy practices with respect to your medical information. We are required to abide by the terms of this Notice when we use or disclose your medical information.

How We May Use and Disclose Medical Information About You

We may use and disclose medical information about you without your prior authorization for the following reasons:

Treatment Purposes. For example, to diagnose and treat your injury or illness. In addition, we may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also disclose your medical information to other providers involved in your treatment.

Payment Purposes. Such as sending billing information to Medicare, Medicaid, your health insurer, HMO, or other company or program that will pay for your health care.

Health Care Operations. For example, we may use your medical information to evaluate the quality and competence of our physicians, nurses and other health care workers. We may disclose medical information to our Patient Advocate in order to resolve any complaints you may have and ensure that you have a comfortable visit with us.

We may also disclose medical information to other health care providers when such medical information is required for them to treat you, receive payment for services they render to you, or conduct certain health care operations, such as quality assessment and improvement activities and reviewing the quality and competence of health care professionals.

Patient Directory. If admitted as a patient, unless you tell us that you object, we will list your name, location, general condition and religious affiliation in the hospital directory. (Religious affiliation will only be disclosed to members of the clergy.) Information in the directory may be released to anyone who asks for you by name or to members of the clergy.

Disclosure to Family, Close Friends and Other Caregivers. We may disclose medical information about you to a family member, other relative, or a close personal friend who is involved in your medical care or to disaster relief authorities so that your family can be notified of your location and condition.

If you are not present, or you are incapacitated or in an emergency situation, we may exercise our professional judgment to decide whether a disclosure is in your best interest. Under these circumstances, we would only disclose information that we believe is directly relevant to the person's involvement with your health care.

Fundraising Communications. We may contact you to request a tax-deductible contribution to support important activities of Methodist Medical Center Foundation. If you wish to make a tax-deductible contribution now or do not want to receive any fundraising requests in the future, you may contact the Methodist Medical Center Foundation at (309) 672-5741.

Other Disclosures. We may also use or disclose medical information about you without your prior authorization for several other reasons. Subject to certain requirements, we may give out medical information about you for: Public Health Activities for the purpose of preventing or controlling diseases; abuse and neglect, to a governmental authority if we reasonably believe you are a victim of abuse, neglect or domestic violence; health oversight activities or inspections, to a health oversight agency that oversees the health care system; judicial, administrative and law enforcement purposes, for example, in response to a subpoena or a request by a law enforcement officer; and we may also disclose your medical information for research studies, funeral arrangements, organ and tissue donations, workers' compensation purposes, your health and safety, and when it is required by law.
Uses and Disclosures Requiring Your Written Authorization

For any purpose other than the ones described above, we will only use or disclose your medical information when you give us your written authorization. For instance, we will obtain your written authorization before sending your medical information to your life insurance company or to the attorney representing the other party in litigation in which you are involved.

Marketing. We will obtain your written authorization prior to using your medical information to send you any marketing materials. We can provide you with marketing materials in a face-to-face encounter without obtaining your authorization. We are also allowed to give you a promotional gift of nominal value, if we so choose, without obtaining your 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 authorization.

Highly Confidential Information. Federal and Illinois law requires special privacy protections for highly confidential information about you. Highly Confidential Information consists of medical information related to: psychotherapy notes; mental health and developmental disabilities services; alcohol and drug abuse services; HIV/AIDS testing, diagnosis or treatment; venereal disease(s); genetic testing; child abuse and neglect; domestic abuse of an adult with a disability; or 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.
Your Rights Regarding Your Medical Information

For Further Information; Complaints. If you have questions or areconcerned that your privacy rights have been violated or you disagree with a decision that we made about access to your medical information, you may contact our Privacy Office. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. Our Privacy Office will provide you with the address. We will not retaliate against you if you file a complaint.\

Right to Request Additional Restrictions. You may request, in writing, that we not use or disclose medical information about you for treatment, payment or health care operations or to persons involved in your care except when specifically authorized by you, when required by law, or in an emergency. We will consider all requests for additional restrictions carefully; however, we are not required to accept them. If you wish to request additional restrictions, please obtain a request form from our Patient Registration Department or the Privacy Office and submit the completed form to the Privacy Office. We will send you a written response.

Right to Receive Confidential Communications. You may request, and we will accommodate, any reasonable written request for you to receive your medical information by alternative means of communication or at alternative locations, such as sending mail to an address other than your home.

Right to Revoke Your Authorization. You have the right to revoke your written authorization obtained in connection with the release of your medical information, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to our Privacy Office. A written revocation form is available upon request from the Patient Registration Department or the Privacy Office.

Right to Inspect and Copy Your Health Information. You have a right to look at or get a copy of your medical record file and billing records maintained by us. Under limited circumstances, we may deny you access to a portion of your records. If you desire access to your records, please obtain a record request form from the Health Information Services Department or your physician's office and submit the completed form to the Health Information Services Department or your physician's office. If you request copies, we may charge a fee for the cost of copying, mailing, or other related supplies.

Right to Amend Your Records. You have the right to request that we amend your medical record file or billing records by obtaining an amendment request form from the Health Information Services Department and submitting the completed form to the Health Information Services Department. We will comply with your request unless we believe that the information is accurate or other special circumstances apply. You have the right to appeal our decision not to amend your medical records.

Right to Receive an Accounting. You may obtainan accounting of certain disclosures of your medical information made by us in the six (6) years prior to your request; however, it does not apply to disclosures that occurred prior to April 14, 2003. If you request an accounting more than once during a twelve (12) month period, we will charge you $0.50 per page of the accounting statement.

Right to Receive Paper Copy of this Notice. Upon request, you mayobtain a paper copy of this Notice, even if you have agreed to receive such Notice electronically.

Right to Change Terms of this Notice. We may change this Notice atany time. If we change this Notice, we may make the new Notice terms effective for all medical information 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 waiting areas around Methodist Medical Center of Illinois and on our Internet site at www.methodistmedicalcenter.org. You also may obtain any new Notice by contacting the Privacy Office.

The effective date of this Notice is April 14, 2003.

Privacy Office

You may contact the Privacy Office at:

Privacy Office Methodist Medical Center of Illinois
221 NE Glen Oak Avenue
Peoria, IL 61636-0002

Phone: (309) 671-8232
E-mail: HIPAAPrivacyOffice@mmci.org