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ALL THE BIG CITY SERVICES WITH THE SMALL TOWN TOUCH

PONDERA MEDICAL CENTER
NOTICE OF PRIVACY PRACTICES

Effective Date: MAY 21, 2021

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.

If you have any questions about this notice, please contact:

Pondera Medical Center
Attn: Privacy Officer
805 Sunset Blvd.
P.O. Box 758
Conrad, MT 59425-0758
(406) 271-3211

WHO WILL FOLLOW THIS NOTICE

This notice describes our practices and that of:

Any health care professional authorized to enter information into your chart.
All departments and units of the organizations covered by this notice.
Any member of a volunteer group we allow to help you.
Any organization that we retain to support operation of this Hospital that has executed an agreement regarding uses and disclosures of your protected health information.

The organizations listed below and the independent members of their Medical Staff (including your physician) have agreed, as permitted by law, to share your health information among themselves for purposes of treatment, payment, or health care operations. This enables us to better address your health care needs.

Pondera Medical Center and Pondera Medical Center Clinic

All these organizations, sites and locations follow the terms of this notice. In addition, these entities, sites and locations may share medical information with each other for treatment, payment or hospital operations purposes described in this notice.

OUR PLEDGE REGARDING MEDICAL INFORMATION

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the protected health information created by any of the organizations listed in this notice. Your doctor may also create information at another hospital or other medical facility. These facilities may have different policies or notices regarding the their use and disclosure of your medical information created by your doctor while at that facility.

This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:

Make sure that medical information that identifies you is kept private
Give you this notice of our legal duties and privacy practices regarding your medical information
Follow the terms of the notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

USE OR DISCLOSURE THAT CAN BE MADE WITHOUT YOUR AUTHORIZATION OR AN OPPORTUNITY FOR YOU TO OBJECT

1. For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. The organizations listed in this notice may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays that are provided by other healthcare organizations. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

2. For Payment. We may use and disclose medical information about you so that the treatment and services you receive at an organization listed in this notice may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about surgery you received so your health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. We may also share information about you and any insurance information with other health care providers to assist them in getting payment for a service they have provided you. For example, we can share this information with a laboratory service that evaluates a laboratory specimen

3. For Health Care Operations. We may use and disclose medical information about you for operation of the organizations listed in this notice. These uses and disclosures are necessary to run the organizations and to make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other organization personnel for review and learning purposes. We may also combine the medical information we have with medical information from other organizations to compare how we are doing and see where we can make improvements in the care and services we offer. We may use your medical information to send questionnaires to you about your experience so that we can identify ways to improve your satisfaction with the services we provide. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are. We may also produce limited data sets that are partially de-identified and that must be used under restrictive agreements for purposes of research, public health, and other healthcare operations described above. We may use disclose your medical information to other health providers who also have a relationship with you for activities related to evaluating the quality of care, for coordinating your care, evaluating the competence of healthcare providers, conducting training, or for fraud or abuse investigation.

4. Fundraising Activities. We may use medical information about you to contact you in an effort to raise money for the organizations and their operations. We may disclose medical information to a foundation related to the organization so that the foundation may contact you in raising money for that organization. We only would release contact information, such as your name, address and phone number and the dates you received treatment or services. If you do not want to be contacted for fundraising efforts, you must notify us in writing:

5. Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another for the same condition. All research projects are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients' need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process, but we may disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave the hospital. We will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at the hospital.

6. As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law.

7. To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. Releases regarding infectious diseases must comply with applicable state laws limiting the release of patient identity and related information.

8. Organ and Tissue Donation. We may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

9. Military and Veterans. If you are a member of the armed forces, we may, release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.

10. Workers' Compensation. We may release medical information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

11. Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following:

To prevent or control disease, injury or disability;
To report births and deaths;
To report child abuse or neglect;
To report reactions to medications or problems with products;
To notify people of recalls of products they may be using;
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;
To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

12. Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

13. Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

14. Law Enforcement. We may release medical information, if asked by a law enforcement official:

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 a crime victim 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.

15. Coroners, Medical Examiners, and Funeral Directors. We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of the hospital to funeral directors as necessary to carry out their duties.

16. National Security & Intelligence. By law, we may release medical information about you to authorized federal officials for intelligence, counterintelligence, or other national security activities.

17. Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

18. Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

USE OR DISCLOSURE WHEN YOU HAVE AN OPPORTUNITY TO OBJECT

Facility Directories and Religious Preferences Unless you object, we may include your name in any facility directory and may list religious preference you tell us in a directory provided to clergy.
Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your general condition and that you are in the hospital. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

USE OR DISCLOSURE THAT CAN ONLY BE MADE WITH YOUR AUTHORIZATION

Uses or disclosures related to treatment for drug or alcohol abuse can be made only with a written authorization or as otherwise required by law. Uses or disclosures for mental health treatment can be made only to professionals for treatment, to obtain payment for services provided, or as otherwise required by state law. All other uses or disclosures can be made only with a written authorization.

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

You have the following rights regarding medical information we maintain about you:

Right to inspect and copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Privacy Officer listed on top of page 1 of this notice.

If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

We may deny your request to inspect and copy in certain very limited circumstances if we judge that disclosing information could be detrimental to you or to another party. You have the right to appeal any such denial.
Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information kept by the organization. To request an amendment, your request must be made in writing and submitted to the Privacy Officer listed on top of page 1 of this notice.
In addition, you must provide a reason that supports your request.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
- Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
- Is not part of the medical information kept by or for the organization;
- Is not part of the information which you would be permitted to inspect and copy; or
- Is accurate and complete.
Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you. To request this list or accounting of disclosures, you must submit your request in writing to the Privacy Officer listed on top of page 1 of this notice.
- Your request must state a time period that may not be longer than six years
- Your request should indicate in what form you want the list (i.e., on paper, electronically)
- The first list you request within a 12-month period will be free
- For additional lists, we may charge you for the cost of providing the list
  - We will notify you of the cost involved and you may choose to withdraw or modify your request at that time, before any costs are incurred
Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.
We Are Not Required To Agree To Your Request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to the Privacy Officer listed on top of page 1 of this notice. 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 spouse. A restriction is not granted until you receive written notice of its approval.
Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to the Privacy Officer listed on top of page 1 of this notice. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice on our web site at ourpmc.com or by contacting the Privacy Officer listed on top of page 1 of this notice.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the hospital or with the Secretary of the Department of Health and Human Services. To file a complaint with the hospital, contact:

Pondera Medical Center
Attn: Privacy Officer
805 Sunset Blvd.
P.O. Box 758
Conrad, MT 59425-0758
(406) 271-3211

All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

CHANGES TO THIS NOTICE

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice at each organization covered by this notice. The notice will contain on the first page, in the top right-hand corner, the effective date.

To Apply:

Contact: Pondera Medical Center
Human Resource Dept.
805 Sunset Blvd
PO Box 758
Conrad, MT 59425
406-271-2235
Fax 406-271-3917
email: [email protected]