Effective Date: April 14, 2003; Revised as of April 17, 2003

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 THIS NOTICE CAREFULLY.

I. SAMARITAN This Notice of Privacy Practices (the “Notice”) applies to information and records regarding your health care maintained by Samaritan. This Notice will be followed by the several components of Samaritan Medical Center including the Hospital, Samaritan Family Health Centers located in Jefferson and Oswego Counties and by Samaritan-Keep Nursing Home. (collectively “SAMARITAN”). All healthcare professionals authorized to enter information into your medical record and independent health care providers involved in your care while practicing at Samaritan will follow this notice. Residents, students and graduate students of health care professional schools affiliated with SAMARITAN and any volunteer we allow to help you while you are a SAMARITAN patient/resident, must follow the privacy practices described in this Notice as well.

II. OUR PLEDGE REGARDING YOUR MEDICAL INFORMATION SAMARITAN is committed to protecting your medical information. We create a record of the care and services you receive at SAMARITAN for use in your care and treatment. This notice applies to all of the records of your care generated by Samaritan, whether made by Samaritan personnel, your personal doctor or other healthcare professionals. Samaritan does not assume any liability for any negligence or professional malpractice committed by the independent health care providers covered under this Notice. Physician practices not owned by Samaritan may have different policies or notices regarding the doctor’s use and disclosure of your protected health information created in the doctor’s office or clinic. This Notice tells you about the ways in which we may use and disclose your medical information. It also describes your rights and certain obligations we have regarding the use and disclosure of your medical information. We are required by law to:
• make sure that your medical information is protected;
• give you this Notice describing 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. If you have any questions regarding this Notice, please call SAMARITAN’s Privacy Officer at (315) 779-5101.

↑ Back to top

III. HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following describes how we may use and disclose your health information for treatment, payment and healthcare operations. Not every type of use or disclosure is listed below, but the ways in which we use or disclose your information will be under one of these purposes.

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, students, or other personnel who are involved in your care. 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, the doctor may need to tell the hospital’s food service if you have diabetes so that we can arrange for appropriate meals. We may also share medical information about you with other SAMARITAN personnel or non-SAMARITAN providers, agencies or facilities in order to provide or coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose medical information about you to people outside SAMARITAN who may be involved in your continuing medical care after discharge such as other health care providers, transport companies, community agencies and family members.

For Payment: We may use and disclose your medical information so that the treatment and services you receive at SAMARITAN or from other entities, such as an ambulance company, 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 information to your health plan about surgery you received at SAMARITAN so your health plan will reimburse you or pay us for the service. We may also tell your health plan about a proposed treatment to determine whether your plan will cover the treatment.

For Health Care Operations: We may use and disclose medical information about you for SAMARITAN operations. These uses and disclosures are made for quality of care and medical staff activities, health sciences education within SAMARITAN, and teaching programs with our affiliates. In addition, your medical information may also be used or disclosed to comply with law and regulations, for contractual obligations, patients’ claims, grievances, lawsuits, health care contracting, legal services, business planning and development, business management and administration, and underwriting and other insurance activities. We may also disclose information to doctors, nurses, technicians, medical and other students, and other personnel for performance improvement and educational purposes.

↑ Back to top

IV. USES AND DISCLOSURES OF INFORMATION IN SPECIAL SITUATIONS We may use or disclose your health information in certain special situations as described below.

Appointment Reminders: We may contact you to remind you that you have an appointment at SAMARITAN.

Treatment Alternatives: We may tell you about possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services: We may contact you to tell you about benefits or services that we provide.

Fundraising Activities: We, or Samaritan Foundation of Northern New York may contact you to provide information about SAMARITAN sponsored activities, including fundraising programs and events. In these instances, we only use contact information, such as your name, address and phone number and the dates you received treatment or services at SAMARITAN. You have the right to request that we not contact you for subsequent fundraising events.

News Gathering Activities: We may contact you or a family member when a news reporter has requested an interview with you. News reporters often seek interviews with patients injured in accidents or experiencing particular medical conditions or procedures. For example, a reporter working on a story about a new cancer therapy may ask whether any of the patients undergoing that therapy might be willing to be interviewed. In such cases, a member of our staff would contact you to discuss whether or not you want to participate in the story. If you choose to participate in the interview, the staff member will obtain your written authorization to do so, and a copy of this authorization will be kept in your medical record.

Hospital Directory: If you are hospitalized, we may include certain limited information about you in the hospital directory. This is so your family, friends and clergy can visit you in the hospital and generally know how you are doing. This information may include your name, location in the hospital, your general condition (e.g., fair, critical, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may only be released to people who ask for you by name. Your religious affiliation may be given to members of the clergy even if they don’t ask for you by name. You may restrict or prohibit the use or disclosure of this information by notifying SAMARITAN’s Patient Registration Department at (315) 785-4095.

Individuals Involved in Your Care or Payment for Your Care: Unless you object, we may release your medical information to anyone involved in your medical care, e.g., a friend, family member, personal representative, or any individual you identify. We may also give your medical information to someone who helps pay for your care. We may also tell your family or friends about your general condition and that you are in the hospital.

Disaster Relief Efforts: We may disclose your medical information to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

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

To Avert a Serious Threat to Health or Safety: We may use and disclose medical information about you when necessary to prevent or lessen a serious and imminent threat to your health and safety or the health and safety of the public or another person. Any disclosure would be to someone able to help stop or reduce the threat.

Organ and Tissue Donation: We may release your medical information to organizations that handle organ procurement or organ, eye or tissue transplantation.

Military and Veterans: If you are or were a member of the Armed Forces, we may release medical information about you to military command authorities as authorized or required by law. We may also release medical information about foreign military personnel to the appropriate military authority as authorized or required by law.

Workers' Compensation: We may use or disclose medical information about you for Workers' Compensation or similar programs as authorized or required by law. These programs provide benefits for work-related injuries or illness.

Public Health Risks: We may disclose medical information about you for public health purposes. These purposes generally include the following:
• preventing or controlling disease, injury or disability;
• reporting vital events such as births and deaths;
• reporting suspected child abuse or neglect;
• reporting adverse events or surveillance related to food, medications or defects or problems with products;
• notifying persons of recalls, repairs or replacements of products they may be using;
• notifying a person who may have been exposed to a disease or may be at risk of contracting or spreading a disease or condition;
• notifying the appropriate government authority if we suspect a patient has been the victim of abuse, neglect or domestic violence and make this disclosure as authorized or required by law.

Health Oversight Activities: We may disclose your medical information to governmental, licensing, auditing, and accrediting agencies as authorized or required by law.

Lawsuits and Other Legal Actions: In connection with lawsuits or other legal proceedings, we may, as authorized or required by law, disclose medical information about you in response to a court or administrative order, or in response to a subpoena, discovery request, warrant, summons or other lawful process.

Law Enforcement: If asked to do so by law enforcement, and as authorized or required by law, we may release your medical information:
• to identify or locate a suspect, fugitive, witness, or missing person;
• about a suspected victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
• about a death suspected to be the result of criminal conduct;
• about alleged criminal conduct at SAMARITAN; and
• in case of a medical emergency, to report a crime; 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: In most circumstances, we may disclose your medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine cause of death. We may also disclose your medical information to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities: As authorized or required by law, we may disclose medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized or required by law.

Protective Services for the President and Others: As authorized or required by law, we may disclose medical information about you to authorized federal officials so they may conduct special investigations or provide protection to the President of the United States, other authorized persons or foreign heads of state.

Inmates: If you are an inmate of a correctional institution or under the custody of law enforcement officials, we may release medical information about you to the correctional institution as authorized or required by law.

↑ Back to top


V. YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
Your medical record is the property of SAMARITAN. You have the following rights, however, regarding medical information we maintain about you: Right to Inspect and Copy: With certain exceptions, you have the right to inspect and/or receive a copy of your medical information. To inspect and/or to receive a copy of your medical information, you must submit your request in writing to SAMARITAN’s Health Information Management Department at 830 Washington Street, Watertown, New York 13601. If you request a copy of the information, there is a fee for these services. The fee may be waived in certain circumstances. We may deny your request to inspect and/or to receive a copy in certain limited circumstances. If you are denied access to your medical information, you may request an appeal of such denial through the New York State Department of Health. Contact Samaritan’s Health Information Management Department at (315)785-4198 to obtain a special Department of Health form to request such an appeal.

Right to Request an Amendment: If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend your medical information. You have the right to request an amendment for as long as the information is kept by or for SAMARITAN. To request an amendment, your request must be made in writing and submitted to SAMARITAN’s Health Information Management Department. 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. In addition, we may deny your request if you ask us to amend information that:
• was not created by SAMARITAN;
• is not part of the medical information kept by or for SAMARITAN;
• is not part of the information which you would be permitted to inspect and copy; or
• is accurate and complete in the record.

Right to an Accounting of Disclosures: You have the right to receive a list of the disclosures we have made of your medical information unless the disclosure was for treatment, payment, health care operations or if you authorized in writing the disclosure of your health information. To request this accounting of disclosures, you must submit your request in writing to SAMARITAN’s Health Information Management Department. Your request must state a time period that may not be longer than the six previous years and may not include dates before April 14, 2003. SAMARITAN will provide you one accounting within any 12-month period at no cost. If you request a second accounting within that 12- month period, there will be a charge for the cost of compiling the accounting. 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 to a family member about a surgery you had. To request a restriction, you must make your request in writing to SAMARITAN’s Health Information Management Department. 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. We are not required to agree to your request. If we do agree, our agreement must be in writing, and we will comply with your request unless the information is needed to provide you emergency treatment.

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 may ask that we contact you only at home or only by mail. To request confidential communications, you must make your request in writing to SAMARITAN’s Health Information Management Department. 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. Copies of this Notice shall be available throughout SAMARITAN, or you may obtain a copy at our website, www.samaritanhealth.com

↑ Back to top
VI. CHANGES TO SAMARITAN’S PRIVACY PRACTICES AND THIS NOTICE We reserve the right to change SAMARITAN’s privacy practices and this Notice. We reserve the right to make the revised 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 physically at various locations at SAMARITAN and electronically on the website. The Notice will contain the effective date on the first page in the top right-hand corner. In addition, you may request a copy of the current Notice in effect.

↑ Back to top

VII. QUESTIONS OR COMPLAINTS If you have any questions about this Notice, please contact SAMARITAN’s Health Information Management Department at (315) 785-4198. If you believe your privacy rights have been violated, you may file a complaint with SAMARITAN or with the Secretary of the United States Department of Health and Human Services. To file a complaint with SAMARITAN, contact the Privacy Officer, telephone number 315-779-5101. For an anonymous complaint reporting, call 877-740-7070 or 315-779-5170. You will not be penalized for filing a complaint.

↑ Back to top

VIII. OTHER USES OF MEDICAL INFORMATION Other uses and disclosures of your medical information not covered by this Notice will be made only with your written authorization. In those instances where your prior written permission for the use and disclosure of your health information is necessary, we will provide you with SAMARITAN’s Authorization Form for you to sign. You may revoke your authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we will retain our records of the care provided to you as required by law.