BOULDER COMMUNITY HOSPITAL
JOINT NOTICE OF PRIVACY PRACTICES

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 Will Follow This Notice.

• Health care practitioners who treat you at any of Boulder Community Hospital's locations, including employees, volunteers, and members of the Hospital's Medical Staff;
• All departments and operating units of our organization;
• All medical practices operated by the Hospital.

Rather than have you read and sign different Notices for each health care practitioner that treats you at each of our operating locations, this Joint Notice of Privacy Practices describes the privacy practices followed by all our practitioners.

Unless your physician is affiliated with one of the BCH medical practices, this notice does not apply to the use and disclosure of your medical information in connection with treatment you receive at your physician's office. Your personal physician may have different policies regarding your medical information and may provide you with a separate Notice. If your physician is affiliated with one of the BCH medical practices, this Notice will apply to your medical information created or maintained at that office.
 

Our Pledge Regarding Medical Information
We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive to ensure that we are providing quality care and to comply with legal requirements. This notice applies to all your health information that we maintain, whether created by our staff or others, and that are shared for purposes of carrying out treatment, payment or health care operations.

We are required by law to give you this Notice of our legal duties and privacy practices, follow the terms of this Privacy Notice, and maintain the privacy of your medical information.

How We May Use and Disclose Medical Information About You
For each category of use or disclosure, we will try to give some examples, not every use or disclosure in the category will be listed.

For Treatment. We may use your medical information to provide you with medical treatment or services. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow your healing. Also, the doctor may need to give information to the dietician so we can arrange for appropriate meals. Different healthcare professionals may also share your medical information in order to coordinate the different services you need. We may disclose your medical information to people outside the hospital who may be involved in your medical care after you leave the hospital.

For Payment. We may disclose your medical information so that treatment and service you receive may be billed to a third party. For example, your health plan may need to know about surgery you received so they will pay us for the surgery. We may also disclose your medical information to obtain prior approval from your Health Plan.

For Healthcare Purposes. We may use and disclose your medical information to make sure that all of our patients receive quality care. For example, we may use medical information to review our processes or to evaluate the performance of those caring for you. We may also disclose information to doctors, nurses, technicians, and other personnel for review and learning purposes. We may remove information that identifies you from this set of information so others may use it to study healthcare and healthcare delivery without learning who the specific patients are.

Hospital Directory. We may disclose certain information about you in the hospital directory while you are a patient. This is so your family, friends and clergy can visit you at BCH and generally know how you are doing. This information includes your name, location in the hospital, your general condition (e. g. fair, stable, etc.), and religious affiliation. The directory information, except for religious affiliation, will be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy even if they don't ask for you by name.

Individuals Involved In Your Care or Payment of Your Care.
We may release your medical information to a friend or family member who is involved in your medical care, or to someone who helped pay for your care.

Contacts. We may contact you to provide appointment reminders, information about treatment alternatives, or other health related benefits and services that may be of interest to you.

Fundraising Activities. We may contact you in an effort to raise money for BCH. We will only use limited information, such as your name, address and dates of service. If you do not want us to contact you, you must notify our Patient Representative in writing at the address below.

Worker's Compensation. We may release medical information about you for worker's compensation or similar programs, which provide benefits for work related injuries or illnesses.

Drug & Alcohol Treatment Records. Specific rules apply to the release of drug and alcohol program records, and the Hospital must obtain specific authorization to release those records as required by Federal Regulation 42 CFR, Part 2.

Miscellaneous. We may use or disclose your medical information without your prior authorization for several other reasons. Subject to certain requirements, we may give out your medical information without prior authorization for public health purposes, abuse or neglect reporting, health oversight audits or inspections, research studies, funeral arrangements, organ donation and emergencies. We also disclose medical information when required by law, such as in response to a request from law enforcement in specific circumstances, or in response to valid judicial or administrative orders. Additional special rules may apply to mental health records.

Other Disclosures. Other uses and disclosures not described above will be made only with your written
authorization. You may revoke your authorization at any time unless we have relied on your authorization or
your authorization was required as a condition of obtaining healthcare services.

Your Rights Regarding Medical Information About You

Right to Inspect and Copy.
In most cases you have the right to inspect or copy your medical information when you submit a written request. We may deny your request in certain circumstances. If you are denied access to your medical information, you may appeal.

Right To Amend. If you believe the information in your record is incorrect or incomplete, you have the right to request an addendum be added to your record by submitting a written request giving your reason. We may deny your request under certain circumstances. If we deny it, we will advise you in writing of the reason and explain your rights to submit a statement of explanation.

Right To An Accounting of Disclosures. You have the right to a list of those instances where we have disclosed your medical information other than for treatment, payment, healthcare operations or where you specifically authorized a disclosure. To request an accounting of disclosures, you must submit a written request to our Patient Representative.

Right To A Paper Copy of This Notice.
If this joint notice was sent to you electronically you have a right to a paper copy of this Notice.

Right To Request Confidential Communications.
You have the right to request that your medical information be communicated to you in a confidential manner, such as sending mail to an address other than your home, by notifying us.

Right To Request Restrictions.
You may request in writing that we not use or disclose your medical information except when specifically authorized by you, when required by law, or in an emergency. We are not required by law to agree to your request, but we will consider it. We will inform you of our decision.

Changes to This Notice
We reserve the right to change this Notice at any time. Changes will apply to medical information we already hold, as well as new information after the change occurs. We will post a copy of our current Notice within our facilities and we will post it on our website at www. bch. org.

Complaints & Requests
If you believe your privacy has been violated, you may file a complaint with the Boulder Community Hospital organization or with the Secretary of the Department of Health and Human Services. All complaints or requests must be submitted in writing to:
Boulder Community Hospital
P. O. Box 9019
Boulder, Colorado 80301-9019.
ATTN: Patient Representative
(Phone #: 303-440-2154)

You will not be penalized for filing a complaint.

Version effective 4/ 14/ 2003