EFFECTIVE DATE OF NOTICE: APRIL 14, 2003

JPS DIAGNOSTIC & SURGERY HOSPITAL OF ARLINGTON
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.

If you have any questions about this notice, please contact the Privacy and Security Program Director at 866-485-2896 (this is a toll-free telephone number)

Your health information is personal.

We are committed to protecting medical information about you. This notice applies to all of the records of your care generated by JPS Diagnostic & Surgery Hospital of Arlington whether made by JPS Diagnostic & Surgery Hospital of Arlington personnel or your health care provider.

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 with respect to medical information about you; and
• follow the terms of the notice that is currently in effect.

Who will follow this notice
This notice describes JPS Diagnostic & Surgery Hospital of Arlington's practices and that of:

• Any health care professional authorized to enter information in your medical record
• All departments of JPS Diagnostic & Surgery Hospital of Arlington
• Any member of a volunteer group
• All employees (contract and non-contract), staff and other JPS Diagnostic & Surgery Hospital of Arlington personnel.
• All JPS Diagnostic & Surgery Hospital of Arlington entities, sites and locations. In addition, JPS Diagnostic & Surgery Hospital of Arlington entities, sites and locations may share medical information with each other for treatment, payment or operation purposes described in this notice.

How we may use and disclose medical information about you
The following categories describe different ways that we use and disclose medical information. Every use or disclosure in a category may not be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

• 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 JPS Diagnostic & Surgery Hospital of Arlington health care professionals 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. In addition, if you are admitted to the hospital, the doctor may need to tell the dietitian if you have diabetes so that appropriate meals for you can be arranged. We also may disclose medical information about you to people outside JPS Diagnostic & Surgery Hospital of Arlington who may be involved in continuing your medical care.
• For Payment. We may use and disclose medical information about you so that the treatment and services you receive may be billed to and payment received from an insurance company, you 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 so we can obtain prior approval or to determine whether your health plan will cover the treatment.
• For Health Care Operations. We may use and disclose medical information about you for Health Care operations. These uses and disclosures are necessary to run JPS Diagnostic & Surgery Hospital of Arlington and 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 JPS Diagnostic & Surgery Hospital of Arlington 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 JPS Diagnostic & Surgery Hospital of Arlington personnel for review and learning purposes. We may also combine the medical information we have with medical information from other health care organizations to compare how we are doing and see where we can make improvements in the care and services we offer. 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 disclosing the identities of patients
• Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care.
• Treatment Alternatives. 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.
• Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
• Fundraising. We may use medical information about you to contact you in an effort to raise money for JPS Diagnostic & Surgery Hospital of Arlington and its operations. We may disclose medical information to a foundation related to JPS Diagnostic & Surgery Hospital of Arlington so that the foundation may contact you in raising money for JPS Diagnostic & Surgery Hospital of Arlington. We only would release contact information, such as your name, address and phone number. If you do not want JPS Diagnostic & Surgery Hospital of Arlington to contact you for fundraising efforts, you must notify Partners Together for Health, 2500 Circle Drive, Fort Worth, TX 76119 in writing.
• Information Directory. If you receive services at JPS Diagnostic & Surgery Hospital of Arlington, we may include certain limited information about you in the information directory. Unless you object, this information may include your name, location, your general condition (for example, fair, stable, etc.) and your religious affiliation. The directory information, except your religious affiliation, may be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as your pastor, priest, or rabbi, even if they don't ask for you by name. This is so your family, friends and clergy can visit you and generally know how you are doing.
• Research. We may disclose information to researchers when their research has been approved by a JPS Diagnostic & Surgery Hospital of Arlington review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information. 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.
• As required by law. We will disclose medical information about you when required to do so by federal, state or local law. For example, all births are reported to the Texas Department of Health Bureau of Vital Statistics.
• 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.
  
  Special situations
• Organ and tissue donation. Upon death we release medical information to organizations that handle organ and tissue procurement.
• Armed Forces and Foreign Military Personnel. 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.
• 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.
• 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 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.
  • 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.
• 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.
• Law enforcement. We may release medical information if asked to do so 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 mission person;
  • about the victim of a crime, 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 JPS Diagnostic & Surgery Hospital of Arlington; and
  • in emergency circumstances to report a crime, this may include the location of the crime or victims, or the identity, description or location of the person who committed the crime.
• Coroners, medical examiners and funeral directors. We may release medical information to a coroner or medical examiner, for example, to identify a deceased person or determine the cause of death. We may also release medical information about JPS Diagnostic & Surgery Hospital of Arlington patients to funeral directors as necessary to carry out their duties.
• National security and intelligence activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
• Protective services for the President of the United States 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.
• 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.

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 your information that may be used to make decisions about your care. This information includes medical and billing records, but does not include psychotherapy notes. To inspect and copy your information, you must submit your request in writing to JPS Health Information Management Services, Release of Information Office, 1500 South Main, Fort Worth, TX 76104. If you request a copy of the information, there will be a charge as set by state law. We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to your information, you may request that the denial be reviewed. Another licensed health-care professional chosen by JPS Diagnostic & Surgery Hospital of Arlington will review your request and the denial. The person conducting the review will not be the person who denied your request. JPS Diagnostic & Surgery Hospital of Arlington will comply with the outcome of the review.
• Right to amend. If you feel that information JPS Diagnostic & Surgery Hospital of Arlington has 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 is kept by and for JPS Diagnostic & Surgery Hospital of Arlington. To request an amendment, your request must be made in writing and submitted to JPS Health Information Management Services, Release of Information Office, 1500 South Main, Fort Worth, TX 76104. 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 information kept by or for JPS Diagnostic & Surgery Hospital of Arlington;
  • 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" by JPS Diagnostic & Surgery Hospital of Arlington of your medical information that occurred in the past six (6) years. The accounting (or list) of disclosures will include: (1) the date of the disclosure; (2) the name of the entity or person who received the medical information and, if known, the address; (3) a brief description of the medical information disclosed; and (4) a brief statement of the purpose of the disclosure. To request this list, you must submit your request in writing to the Privacy and Security Program Director, JPS Diagnostic & Surgery Hospital of Arlington, 4400 New York Avenue, Arlington, TX 76018. Your request must state a time period that may not be longer than six (6) years and may not include dates before April 14, 2003; however, the time period certainly may be less than six (6) years. The first list you request within a twelve (12) month period will be free of charge. For additional lists, we may charge you for the costs 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, such as a family member or friend. For example, you could ask that we not use or disclose information about a particular surgery that you have 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 with emergency treatment. To request restrictions, you must make your request in writing the Privacy and Security Program Director, JPS Diagnostic & Surgery Hospital of Arlington, 4400 New York Avenue, Arlington, TX 76018. In your request, you must tell us: (1) what information you want to limit; (2) whether you want to limit our use or disclosure of the information (or both); and (3) to whom you want the limits to apply (for example, disclosures to your spouse).
• Right to request confidential communications. You have the right to request that we communicate with you 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 and Security Program Director, JPS Diagnostic & Surgery Hospital of Arlington, 4400 New York Avenue, Arlington, TX 76018. We will not ask you for 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. To obtain a paper copy of this Notice, contact the Privacy and Security Program Director or a patient registration representative. You may also obtain an electronic copy of this Notice at our web site, http://www.dsharlington.org.

  Changes to this notice
  JPS Diagnostic & Surgery Hospital of Arlington reserves the right to change this notice. We reserve the right to make the revised or changed notice effective for 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. The notice will contain on the first page in the top right-hand corner, the effective date. In addition, each time you register at or are admitted to JPS Diagnostic & Surgery Hospital of Arlington for services, we will offer you a copy of the current notice in effect.

  Complaints

  1. If you believe your privacy rights have been violated, you may file a complaint with the Network or the Secretary of the United States Department of Health and Human Services. To file a complaint with JPS Diagnostic & Surgery Hospital of Arlington, contact the Privacy and Security Program Director, JPS Diagnostic & Surgery Hospital of Arlington, 4400 New York Avenue, Arlington, TX 76018. You will not be penalized or retaliated against in any way for making a complaint to the Hospital or the Department of Health and Human Services. All complaints to the Hospital must be submitted in writing.

  Other uses for information
  Other uses and disclosures of information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose 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 information about you for the reasons covered by your written authorization. We are unable to take back any disclosures we have already made with your permission. Additionally, we are required to retain our records of the care that we provided you.