Notice of Privacy Practices: How Your Medical Information is used.

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.

Understanding Your Health Information

Each time you visit Family Health Care of Siouxland, a record of your
visit is made. Typically, this health record contains your medical history,
symptoms, examination and test results, diagnosis, treatment, care plan,
insurance, billing, and employment information. This health information,
often referred to as your health record, serves as a basis for planning your
care and treatment and is a vital means of communication among the
many health professionals who contribute to your health care. Your health
information is also used by insurance companies and other third-party
payers to verify the appropriateness of billed services.

Our Responsibilities

We are required by law to:

  • Maintain the privacy of your health information.
  • Provide you with an additional current copy of our Notice upon request.
  • Abide by the terms of our current Notice.

We will not use or disclose your health information without your written
authorization, except as described in this Notice. Such authorization may be
revoked in writing at any time except with respect to any actions we have
taken in reliance on it.

Examples of Using Health Information for Treatment,
Payment and Health Care Operations

We will use and disclose your health information for treatment purposes

For example: Information obtained by a nurse, physician or other member of
your health care team will be recorded in your record and used to determine
the course of treatment. Health care team members will communicate with
one another personally and through the health record to coordinate care
provided. We will also provide your physician or subsequent health care
provider with copies of various reports that should assist him or her in
treating you in the future.

We will use and disclose your health information for payment purposes

For example: A bill may be sent to you or a third-party payer. The
information on or accompanying the bill may include information that
identifies you, as well as your diagnosis, procedures, and supplies used.
We may disclose health information about you to other qualified parties for
their payment purposes. For example, if you are brought in by ambulance,
we may disclose your health information to the ambulance provider for its
billing purposes.

We will use and disclose your health information for health care
operations

For example: Members of the medical staff, the risk or quality improvement
manager, or members of the quality improvement team may use information
in your health record to assess the care and outcomes in your case and others
like it. This information will then be used in an effort to continually improve
the quality and effectiveness of health care we provide. In some cases,
we will furnish your health information to other qualified parties for their
health care operations. The ambulance company, for example, may want
information regarding your condition to help them know whether they have
done an effective job of stabilizing your condition.

Health Information Exchange

We may make your protected health information available electronically
through an information exchange service to other health care providers,
health plans and health care clearinghouses that request your information.
Participation in information exchange services also lets us see their
information about you.

Other Uses and Disclosures of Your Health Information
Notification

We may use or disclose health information to notify or assist in notifying a
family member, personal representative, or another person responsible for
your care of your location and general condition.

Communication with Family and Others

We may disclose relevant health information to a family member, friend, or
other person involved in your care. We will only disclose this information
if you agree, are given the opportunity to object and do not, or if in our
professional judgment, it would be in your best interest to allow the person
to receive the information or act on your behalf.

Decedents

We may make relevant disclosures to the deceased’s family and friends
under essentially the same circumstances such disclosures are permitted
when the patient was alive. That is when these individuals were involved
in providing care or payment for care and we are aware of any expressed
preference to the contrary. The privacy rule eliminates the protection of
protected health information 50 years after a patient’s death.

Business Associates

There are some services provided in our organization through contracts with
business associates. When these services are contracted, we may disclose
your health information to our business associates so that they can perform
such services. However, we require the covered entity to appropriately
safeguard your information.

Public Health

We may disclose health information about you for public health activities.
These activities may include disclosures:

  • To a public health authority authorized by law to collect or receive such
    information for the purpose of preventing or controlling disease, injury,
    or disability;
  • To appropriate authorities authorized to receive reports of abuse and
    neglect;
  •  To FDA-regulated entities for purposes of monitoring or reporting the
    quality, safety or effectiveness of FDA-regulated products; or 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.

Workers’ Compensation

We may disclose health information to the extent authorized and necessary
to comply with laws relating to workers’ compensation or other similar
programs established by law.

Childhood Immunizations

We may disclose immunizations to schools required to obtain proof of
immunization prior to admitting your student so long as we have and
document the student(s) legal representative’s “informal agreement” to the
disclosure.

Correctional Institutions

If you are an inmate of a correctional institution or under custody of a law
enforcement official, we may disclose to the correctional institution, its
agents or the law enforcement official your health information necessary for
your health or the health and safety of other individuals.

Law Enforcement

We may disclose health information if asked to do so by a law enforcement
official as required or permitted by law or in response to a subpoena.

Health Oversight Activities

We may disclose health information for health oversight activities authorized
by law. For example, oversight activities include 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.

Threats to Health or Safety

Under certain circumstances, we may use or disclose your health
information if we believe it is necessary to avert or lessen a serious threat
to health and safety and is to a person reasonably able to prevent or lessen
the threat or is necessary for law enforcement authorities to identify or
apprehend an individual involved in a crime.

Specialized Government Functions

We may disclose your information for national security and intelligence
activities authorized by law, for protective services of the president; or if you
are a military member, to the military under limited circumstances.

As Required by Law
We will use or disclose your health information as
required by federal, state or local law.

Lawsuits and Administrative Proceedings

We may release your health information in response to a court or
administrative order. We may also provide your information in response to
a subpoena or other discovery request, but only if efforts have been made
to tell you about the request or to obtain an order protecting the information
requested.

Funeral Directors, Medical Examiners, and Coroners

We may disclose your health information to funeral directors, medical
examiners, and coroners consistent with applicable law to carry out their
duties.

Organ Procurement Organizations

Consistent with applicable law, we may disclose health information to organ
procurement organizations or other entities engaged in the procurement,
banking, or transplantation of organs for the purpose of tissue donation and
transplant.

Incidental Uses and Disclosures

There are certain incidental uses or disclosures of your health information
that occur while we are providing services to you or conducting our
business. For example, after a procedure the nurse or doctor may need to
use your name to identify family members that may be waiting for you in a
waiting area. Other individuals waiting in the same area may hear your name
called. We will make reasonable efforts to limit these incidental uses and
disclosures.

Patient Surveys

You may be asked to complete a survey. We use information from surveys
to better understand the needs of our patients and to gather information
about health care trends and issues. We generally do not ask for information
in surveys that would personally identify you. If we do request contact
information for follow-up, you may decline to provide it. If survey
respondents provide personal information (such as an email address) in a
survey, it is shared only with those people who need to see it to respond to
the question or request, or with third parties who perform data management
services for our site. Those third parties have agreed to keep all data from
surveys confidential. Also, we may share information from surveys in an
aggregated, de-identified form with third parties with whom we have a
business relationship.

Patient On-Line Services, E-mail Communications, Newsletter and
related services

Family Health Care provides you with the opportunity to receive
communications from us or third parties. You can sign up for our free Patient
On-Line Services via submitting your email address at any clinic or through
our website www.fhcsl.com. You can unsubscribe from this at anytime.
Email communication that you send to us via the Patient On-Line Services
links on our site may be shared with our staff that are most able to
address your inquiry. We make every effort to respond in a timely fashion
once communications are received. Once we have responded to your
communication, it is saved to your electronic chart.

How we and our affiliates collect and use personal information

Family Health Care’s website may contain links to websites operated by
third parties. Our website, www.fhcsl.com, has no control over the privacy
policies and practices of such third party sites, and if you have any concerns,
you are urged to review the terms of those sites for more information about
the policies applicable to those sites.

Marketing Communication

  1. We have the right to notify you of third-party products or services without
    written authorization when:
    The physician/provider receives no compensation for the communication
  2. The communication is face-to-face
  3. The communication involves a drug or biologic the patient is currently
    being prescribed
    and the payment is limited to reasonable reimbursement of the costs of
    the communication (no profit)
  4. The communication involves general health promotion, rather than the
    promotion of specific products or services
  5. The communication involves government or government-sponsored
    programs

We are permitted to give patients promotional gifts of nominal value (e.g.
pamphlets)

Sale of Protected Health Information

We are prohibited from selling your protected health information in the
absence of a written authorization. This also extends to licenses and lease
agreements, and to the receipt of financial or in-kind benefits. This also
includes disclosures in conjunction with research if the remuneration
received includes any profit margin. On the other hand, the prohibited sale
does not extend to permit disclosures for payment or treatment nor to permit
disclosures to patients or their designees in exchange for a reasonable costbased fee.

Your Health Information Rights
You have the following rights regarding your health
information:

Right to Inspect and Copy

You may request a copy of your medical records. We have 30 days to
respond to a written request for your PHI with one 30 day-extension. Our
records are in an electronic format. Therefore, we will provide a copy of
your medical record electronically via one of the following methods:

  1. Secure Patient Online Service
  2. Family Health Care provided new USB/Memory Stick

Hard copies are permitted only when you, as the patient, reject all readily
reproducible e-formats.
If you request a copy of your records in any format, we may charge you a
fee.

Right to Request Amendment

You may request that your health information be amended if you feel that
the information is not correct. Your request must be in writing and provide
rationale for the amendment. Please send your request to the Medical
Records Department. We may deny your request, and will notify you of our
decision in writing.

Right to an Accounting of Disclosures

You may request an accounting of certain disclosures of your health
information showing with whom your health information has been shared
(does not apply to disclosures to you, with your authorization, for treatment,
payment or health care operations, and in certain other cases).
To request an accounting of disclosures, you must send a written request to
the Medical Records Department. Your request must state a time period that
may not be longer than six years and may not include dates before April 14,
2003.

Right to Request Restrictions

You may request restrictions on how your health information is used for
treatment, payment or health care operations, or to certain family members
or others who are involved in your care. At the patient’s request we may not
disclose information about your care that you have paid out-of-pocket to
health plans, unless for treatment purposes or in the rare event the disclosure
is required by law.
To request a restriction, you must send a written request to the Medical
Records Department, specifying what information you wish to restrict and
to whom the restriction applies. You will receive a written response to your
request.

Right to Request Private Communications

You may request that we communicate with you in a certain way in a certain
location. You must make your request in writing to the patient registration
area and explain how or where you wish to be contacted.

Right to a Paper Copy of this Notice

You may request an additional copy of this Notice at any time from any
Family Health Care facility listed on the front of this booklet.

Policy updated 03/2013

This Notice applies to the following Family Health Care locations:

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Sleep Center
345 West Steamboat Drive, Suite 404
Dakota Dunes, SD 57049

Dakota Dunes Clinic
345 West Steamboat Drive, Suite 300
Dakota Dunes, SD 57049

Indian Hills Clinic
2600 Outer Drive N
Sioux City, IA 51104

Morningside Clinic
Morningside Urgent Care
4545 Sergeant Road
Sioux City, IA 51106

South Sioux City Clinic
3250 Plaza Drive
South Sioux City, NE 68776

Corporate Offices
814 Pierce Street, Suite 300
Sioux City, IA 51101

Imaging Center
345 West Steamboat Drive, Suite 401
Dakota Dunes, SD 57049

Northside Clinic
Northside Urgent Care
4230 Hamilton Boulevard
Sioux City, IA 51104

The organizations listed will use and distribute this Notice
as their Joint Notice of Privacy Practices and follow the
information practices described in this Notice when using
or disclosing records and information. They will share your
health information with each other, as necessary, to carry out
treatment, payment, or health care operations as described in
this Notice.

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