PRIVACY NOTICE

THE FOLLOWING 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.

Clarendon Memorial Hospital (“CMH”) and all the members of the CMH medical staff (referred to in this Notice as “we,” “us,” or the “Hospital”) understand that information about you and your health is private. We will refer to your health information in this Notice as your “protected health information” or “PHI.” We are committed to protecting the privacy and confidentiality of your protected health information. This Notice is required by law and applies to the entire PHI contained in the records of your care generated at or maintained by the Hospital, whether made by Hospital personnel, or by a member of our medical staff or by another health care provider.

HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION:

• TREATMENT: We may use and disclose your protected health information to provide, coordinate and manage your healthcare and any related health services. We may disclose your protected health information to other healthcare providers or third parties who are involved in your treatment. We may also use or disclose your protected health information in consultation with other healthcare providers relating to your care or to refer you for health care to another provider. An example of a use or disclosure for treatment: The information recorded in your health record by your physician and other members of your healthcare team will be used to determine the best course of treatment for you. Your physician will record his or her orders regarding your treatment. Healthcare team members from various departments will record their actions and observations in carrying out those orders so that your physician will know how you are responding to treatment.

• PAYMENT: We may use and disclose your protected health information to bill and collect payment for your healthcare services from you, your insurer or a third party. We may also use and disclose your protected health information to:

- Make eligibility and coverage decisions
- Seek judgment on or subrogate health benefit claims
- Perform risk adjusting activities
- Review services provided to you for
- Medical necessity determination
- Coverage under a health plan
- Appropriateness of care
- Justification of charges
- Support utilization review activities

An example of a use or disclosure for payment: We will bill your third-party payer(s) for the healthcare services we provide. The information on the bill may include information that identifies your diagnoses, treatment and supplies used.

• HEALTH CARE OPERATIONS: We may use or disclose your protected health information to support those activities necessary to run our facility and to assure that you receive high quality healthcare services. We call those activities health care operations. We may use or disclose your protected health information to:

- Conduct quality assessment and improvement activities
- Review the competence or qualification of health care professionals, evaluate practitioner performance, and conduct training programs for students, trainees, practitioners or non-health care professionals
- Conduct accreditation, certification, licensing or credentialing activities
- Conduct activities related to the creation, renewal or replacement of a contract of health insurance or health benefits
- Conduct or arrange for medical review, legal services, and auditing functions
- Provide for business planning and development
- Provide for business management and general administration

An example of a use or disclosure for health care operations: Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.

• Appointment Reminder, Treatment Options or Health-Related Benefits and Services: We may contact you to remind you of any appointments, healthcare treatment options or other health services that may be of interest to you. For example: We may contact you in advance of a procedure that has been scheduled by your physician at our facility to remind you of the scheduled date and time.

• As Required By Law: We may use or disclose your protected health information to the extent that federal, state or local law requires such use or disclosure.
• For Public Health Activities: We may use or disclose your protected health information to a public health authority to:

- Prevent or control disease, injury or disability
- Report child abuse or neglect
- Report adverse events with respect to food, drugs and product defects
- Enable product recalls, repairs or replacement

We may also disclose protected health information to your employer, as allowed by occupational health and safety laws, regarding work-related illness or injury or concerning medical surveillance activities.

• For Abuse, Neglect or Domestic Violence Reporting: If we believe that you have been a victim of abuse, neglect or domestic violence, we may disclose your protected health information to a government authority or agency authorized by law to receive such reports.
• For Health Oversight Activities: We may disclose your protected health information to a health oversight agency for activities authorized by law, such as audits, civil, administrative or criminal investigations, inspections, licensure or disciplinary actions.
• For Legal Proceedings: We may disclose your protected health information in the course of any judicial or administrative proceedings in response to an order of the court, administrative tribunal, subpoena, discovery request or other lawful request.
• For Law Enforcement Activities: We may disclose your protected health information for law enforcement purposes in response to a court order, court ordered warrant, subpoena, summons, a grand jury subpoena, administrative request or similar process.
• Coroners, Medical Examiners and Funeral Directors: We may disclose your protected health information to coroners, medical directors or funeral directors as required by law to carry out their duties.
• For Organ and Tissue Donation: If you are an organ donor, we may use or disclose your protected health information to organ procurement organizations or other organizations that handle procurement, banking or transplantation of organs for the purpose of tissue donation and transplantation.
• For Research: We may use or disclose your protected health information to researchers provided that the use or disclosure has been approved and procedures have been established to ensure the privacy of your protected health information.
• To Prevent Serious Threat to Health or Safety: We may use or disclose your protected health information if, in good faith, we believe the use or disclosure is necessary to prevent or lessen a serious threat to your health and safety or to the health and safety of the public or another person.
• Military Activity, Veterans, and National Security: If you are a member of the Armed Forces, we may use or disclose your protected health information for activities deemed necessary by appropriate military command authorities to assure the proper execution of the military mission. We may disclose protected health information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
• Worker’s Compensation: We may use or disclose your protected health information to comply with worker’s compensation or other similar programs established by law for work-related injuries or illness.
• For Fundraising: We may use or disclose your demographic information and the dates on which health care was provided to you to contact you to raise funds for the Hospital.
Other Uses and Disclosures of your Protected Health Information That May Be Made if we provide you with the Opportunity to Object.
• Facility Directory: Unless you notify us that you object, we will use and disclose your name, location in the facility, condition (in general terms) and religious affiliation for directory purposes. This information, except for religious affiliation, will be disclosed to people who ask for you by name. Only members of the clergy will be told of your religious affiliation.
• Notification to Individuals Involved in your Care: We may use or disclose protected health information to a family member, close friend, or any other person you identify to the extent it is relevant to that person’s involvement in your treatment. We may also disclose your protected health information to your family or friends if it is apparent from the circumstances and based on our professional judgment that you would not object. For example, we may assume that you do not object to disclosure of your protected health information to your spouse if you permit your spouse to accompany you during treatment or to be present while treatment is discussed. We may disclose protected health information about you to an entity assisting in a disaster relief effort so your family can be notified about your condition, status and location.

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

• Other uses and disclosures of your PHI will be made only with your written authorization for its use or disclosure. You may revoke your authorization to use or disclose your protected health information at any time except to the extent that your PHI has already been used or disclosed before you revoked your authorization. You must revoke your authorization in writing.
• If we receive PHI from a facility covered by the Alcohol and Drug Rehabilitation Act, or if we receive or create certain psychiatric protected health information, we will not further disclose that PHI without your express permission or as allowed or required by law.

YOUR RIGHTS CONCERING YOUR PROTECTED HEALTH INFORMATION AND THIS NOTICE

You have the right to:

• Amend Your Health Record: If you believe the protected health information we have about you is incorrect or incomplete, you may ask us to amend the information for as long as we maintain your protected health information. If you wish to request an amendment, then you must do so in writing and submit that request to Chief Privacy Officer, Clarendon Memorial Hospital, 10 Hospital Street, Manning, South Carolina, 29102. The request must provide the reason(s) you are making the request. Your request may be subject to certain exceptions and limitations. We may deny your request to amend your protected health information.
• Inspect and Copy Your Health Information: You have the right to inspect and copy your protected health information. You must submit a written request to Chief Privacy Officer, Clarendon Memorial Hospital, 10 Hospital Street, Manning, South Carolina, 29102 in order to inspect and/or copy your protected health information. In certain circumstances, we may deny your request to inspect and/or copy your records. If you request a copy of your health information, reasonable copying fees may be charged.
• Receive an Accounting of Disclosures: You have the right to receive an accounting of disclosures of your protected health information that we may make after April 14, 2003 but within six (6) years of the date of the request. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices and certain other disclosures. The right to receive this information is subject to certain exceptions, restrictions and limitations. If you wish to request an accounting, then you must do so in writing and submit that request to Chief Privacy Officer, Clarendon Memorial Hospital, 10 Hospital Street, Manning, South Carolina, 29102. The first request for an accounting within any 12-month period will be provided to you at no charge. We may charge you a reasonable copying fee for additional requests.
• Request Restrictions: You have the right to request restrictions or limitations on the protected health information we use or disclose about you. If you wish to request an a restriction, then you must do so in writing and submit that request to Chief Privacy Officer, Clarendon Memorial Hospital, 10 Hospital Street, Manning, South Carolina, 29102. The written request must include the protected health information you wish to restrict, whether you want to restrict its use or disclosure or both, and to whom you wish the restrictions to apply. We are not required to agree to your request for restriction. If the restricted protected health information is needed to provide emergency treatment, we may disclose such information to your health care provider for the purpose of providing treatment.
• Request Confidential Communications: You may request that we communicate with you about your protected health information in a certain way or at a certain location. We will accommodate reasonable requests. For example, you may request that we contact you at work. If you wish to request confidential communications, you must make the request in writing and submit it to Chief Privacy Officer, Clarendon Memorial Hospital, 10 Hospital Street, Manning, South Carolina, 29102. The request must include how and where you wish to be contacted.
• Obtain a Paper Copy of This Notice: You have a right to obtain a paper copy of this Notice of Privacy Practices even if you have agreed to receive it electronically. We will provide you with a Notice upon your request.

REQUIREMENTS OF OUR FACILITY

• We are required by law to maintain the privacy of your protected health information and to abide by the terms of this Notice. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all the protected health information that we maintain. Upon your request, we will provide you with a revised Notice. You may request a revised Notice be sent to you in the mail or you may ask for a revised copy at the time of your next visit.

COMPLAINTS

• You have the right to complain to us if you believe your rights to privacy have been violated. You may also complain to the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint. We ask that you submit your complaint in writing to:

ATTN: Chief Privacy Officer
Darman Weaver
Clarendon Health System
10 Hospital Street
P.O. Box 550
Manning, SC 29102

CONTACT INFORMATION

• For further information about this Privacy Notice, please contact: Darman Weaver, Chief Privacy Officer at 803.435.8463.

This notice is effective as of April 14, 2003.