JOINT NOTICE OF PRIVACY PRACTICES

COLQUITT REGIONAL MEDICAL CENTER

Including the following Affiliated Covered Entities:

Colquitt Regional Home Health Services Colquitt Regional Private Duty Services Colquitt Regional Community Care Services Colquitt Regional Hospice Services Colquitt Regional Non-Emergency Transport

Colquitt Regional Ambulance Services Colquitt Regional Dialysis Services Colquitt Regional Primary Care Center Colquitt Regional Med+Care Center

Colquitt Regional Medical Center and the hospital’s medical staff members participate in an organized health care arrangement. This Joint Notice of Privacy Practices applies to services you receive while a patient in this hospital or any of its affiliated covered entities. The hospital employees and the medical staff members will share your protected health information with each other, as necessary to carry out treatment, payment, or health care operations relating to your care in any of these facilities. The parties of the Organized Health Care Arrangement do not assume joint or several liability.

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.

Hospitals create and maintain records of medical information. While you are a patient here, we will use and disclose your medical information:

· To provide treatment to you and to keep a record describing your care

· To receive payment for the care we provide

· To operate the hospital properly

· To comply with the law

When we use the word “we” or “hospital” we mean Colquitt Regional Medical Center, its affiliates, medical professionals and other parties who assist us in our business.

WE ARE REQUIRED BY LAW to protect the privacy of health information that can be identified with you, which we call “protected health information,” or “PHI” for short. We must give you notice of our legal duties and privacy practices concerning PHI. We must explain how, when and why we use and/or disclose PHI about you. We may only use and/or disclose PHI as we have described in this Notice. We reserve the right to change the terms of this Notice and to make new Notice provisions effective for all PHI that we maintain by first:

· Posting the revised Notice in the facility

· Making copies of the revised Notice available upon request and

· Posting the revised Notice on our website

WE MAY USE AND DISCLOSE PHI ABOUT YOU WITHOUT YOUR AUTHORIZATION IN THE FOLLOWING CIRCUMSTANCES:

1. We may use and disclose PHI about you to provide health care treatment to you.

We may use and disclose PHI about you to provide, coordinate or manage your health care and related services. This may include communicating with other health care providers regarding your treatment and coordinating and managing your health care with others. For example, we may use and disclose PHI about you when you need a prescription, lab work, an x-ray, or other health care services. In addition, we may use and disclose PHI about you when referring you to another health care provider.

2. We may use and disclose PHI about you to obtain payment for services.

Generally, we may use and give your medical information to others to bill and collect payment for the treatment and services provided to you. Before you receive scheduled services, we may share information about these services with your health plan(s). Sharing information allows us to ask for coverage under your plan or policy and for approval of payment before we provide the services. For example, we may also share portions of your medical information with the billing department, collection agencies or insurance companies for payment of your health care service.

3. We may use and disclose your PHI for health care operations.

We may use and disclose PHI in performing business activities, which we call “health care operations”. These “health care operations” allow us to improve the quality of care we provide and reduce health care costs. Examples of the way we may use or disclose PHI about you for “health care operations” include the following:

• Reviewing and improving the quality, efficiency and cost of care that we provide to you and to our other patients. For example, we may use PHI about you to develop ways to assist our health care providers and staff in deciding what medical treatment should be provided to others.
• Working with outside organizations to improve our customer satisfaction. For example: You may be contacted by an outside organization to complete a survey regarding your stay in the hospital.

• We may use a sign-in sheet at the registration desk where you will be asked to sign your name.
• We will share your protected health information with third party “business associates” that perform various activities (e.g., billing, transcription services) for the hospital.

4. We may use and disclose PHI under other circumstances without your authorization.

We may use and/or disclose PHI about you for a number of circumstances in which you do not have to consent, give authorization or otherwise have an opportunity to agree or object. Those circumstances include: When the use and/or disclosure

• Is required by law.
• Is necessary for public health activities. When the disclosure relates to victims of abuse, neglect or domestic violence.
• Is for judicial and administrative proceedings.
• Is for law enforcement purposes.
• Relates to decedents. For example, we may disclose PHI about you to a coroner or medical examiner for the purposes of identifying you should you die.
• Relates to cadaveric organ, eye or tissue donation purposes.
• Is to avert a serious threat to health or safety.
• Relates to specialized government functions.
• Relates to you as a member of the U.S., or foreign armed forces regarding information required by military command authorities.
• Relates to you as an inmate in correctional institutions and in other law enforcement custodial situations.
• Relates to workers’ compensation or similar programs.

5. You can object to certain uses and disclosures.

Unless you object, we may use or disclose PHI about you in the following circumstances:

• We may share your name, your room number, and your condition in our patient listing with clergy and with people who ask for you by name. For example, your name will be listed in our hospital directory. Your religious affiliation may be given to a member of the clergy, such as a priest, rabbi or pastor, even if they don’t ask for you by name.
• We may share with a family member, relative, friend or other person identified by you, PHI directly related to that person’s involvement in your care or payment for your care. We may share with a family member, personal representative or other person responsible for your care PHI necessary to notify such individuals of your location, general condition or death.
• We may share with a public or private agency (for example, American Red Cross) PHI about you for disaster relief purposes. Even if you object, we may still share the PHI about you, if necessary for the emergency circumstances.

If you would like to object to our use or disclosure of PHI about you in the above circumstances, please call our contact person listed on the last page of this Notice.

6. We may also use and disclose PHI under the following special circumstances.

• We may disclose your medical information to a federal or state agency for health oversight activities such as audits, investigations, inspections, and licensures.

• We may contact you to provide appointment reminders.
• We may contact you with information about treatment, services, products or health care providers.
• We may contact you for fundraising activities for the Medical Center and its operations.

Note: Georgia and Federal Law provide protection for certain types of health information, including information about alcohol or drug abuse, mental health and AIDS/HIV, and may limit whether and how we may disclose information about you to others.

Minors: If you are a minor (under 18 years old), we will comply with Georgia law regarding minors. We may release certain types of your medical information to your parent or guardian, if such release if required or permitted by law.

ANY OTHER USE OR DISCLOSURE OF PHI ABOUT YOU REQUIRES

YOUR WRITTEN AUTHORIZATION

Under any circumstances other than those listed above, we will ask for your written authorization before we use or disclose PHI about you. If you sign a written authorization allowing us to disclose PHI about you in a specific situation, you can later cancel your authorization in writing. If you cancel your authorization in writing, we will not disclose PHI about you after we receive your cancellation, except for disclosures processed before we received your cancellation.

YOUR PRIVACY RIGHTS

1. You have the right to request restrictions on uses and disclosures of PHI about you.

You may request a restriction by contacting the Privacy Officer. We are not required to agree to your requests. However, if we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment or to make a disclosure that is required under law. 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 adult children.

2. You have the right to receive confidential communications by requesting that we communicate with you in certain ways. We will accommodate reasonable requests. We may condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not require you to provide an explanation for your request. Requests must be made in writing to our Privacy Officer.

3. You may inspect and obtain a copy of your protected health information that is contained in a designated record set for as long as we maintain the protected health information. To inspect and copy your medical information, you must submit a written request to the Privacy Officer whose contact information is listed on the last pages of this Notice. If you request a copy of your information, we may charge you a fee for the costs of copying, mailing or other costs incurred by us in complying with your request.

4. You have the right to request that we amend your protected health information contained in a designated record set. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Requests for amendment must be in writing and must be directed to our Privacy Officer. In this written request, you must also provide a reason to support the requested amendments.

5. You have the right to request a listing of certain disclosures of your protected health information made by The Medical Center. The request for a listing of disclosure must be made in writing to our Privacy Officer. The request should specify the time period sought for the listing. We are not required to provide a listing of disclosures that take place prior to April 14, 2003. Accounting requests may not be made for periods of time in excess of six years. We will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.

6. You have a right to a copy of this Notice. Upon request, we will provide a separate paper copy of this Notice even if you have already received a copy of the notice or have agreed to accept this Notice electronically.

COMPLAINTS

You have the right to express complaints to The Medical Center and to the Secretary of Health and Human Services if you believe that your privacy rights have been violated. You may complain to the Medical Center by contacting the provider’s Privacy Officer verbally or in writing, using the contact information below. The U.S. Department of Health and Human Services may be contacted at: 200 Independence Avenue S.W., Washington, D.C. 20201; Telephone: 202-619-0257; Toll Free: 1-877-696-6775. We encourage you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.

CONTACT PERSON

The hospital’s contact person for all issues regarding patient privacy and your rights under the Federal privacy standards is the Privacy Officer. Information regarding matters covered by this Notice can be requested by contacting our Privacy Officers. Complaints against the provider can be mailed to the hospital’s Privacy Officers by sending it to Linda Wilson or Faye Kelly, 3131 South Main Street, P. O. Box 40, Moultrie, Georgia 31776-0400. The privacy officers may be contacted by phone or email: Linda Wilson at 229-890-3439 or lwilson@colquittregional.com and Faye Kelly at 229-890-3566 or fkelly@colquittregional.com

This Notice is effective April 14, 2003

Colquitt Regional Medical Center

P. O. Box 40

Moultrie, Georgia 3l776-0040

www.colquittregional.com