Effective Date: April 14, 2003

WHO WILL FOLLOW THIS NOTICE: This notice applies to all the clinics and departments of Milford Hospital. It applies to our entire workforce including our physicians, employees, students, and volunteers.

HOW WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION
The following categories show the different ways we may use and disclose to others your medical information. For each category we give some examples, but not every use or disclosure in a category is listed. Your health information will not be used or disclosed for purposes other than those described in this notice without your authorization.

For Treatment: Your health information may be used or released to other healthcare professionals to provide you with medical treatment or services, as well as emergency care provided in another facility. We may share information about you with doctors, nurses, technicians, or other healthcare professionals involved in taking care of you. For example, a doctor treating you for a broken leg may need to know if you have diabetes since that could affect the healing process. Other health care professionals may need to share your information to coordinate your care with people outside the Hospital such as for prescriptions, lab work, and x-rays. And we may disclose information about you to people outside the Hospital who may be involved in your medical care after you leave the Hospital.

For Payment: Your health information may be used and disclosed by the Hospital so that the Hospital can receive payment from you, your insurance company, or a third party, for providing you with needed healthcare services. For example, your insurance company may need to know about the surgery you received so that they will pay us or reimburse you. The Hospital may also disclose your information to obtain prior approval for your care or to determine if your insurance policy will cover the treatment.

For Hospital Functions Other than Treatment and Payment: Your health information may be used or disclosed for a variety of healthcare-related purposes which are necessary for the Hospital to function. We may use your information to ensure that all our patients receive quality care and to ensure that the Hospital continues to earn professional accreditation. For example, we may use your information so that the Hospital can evaluate the performance of our staff in caring for you.

In addition, we may utilize your information to contact you for purposes such as the following:

• Appointment reminders: We may disclose your information to contact you as a reminder that you have an upcoming appointment for an office visit, lab test, or other treatment.
• Treatment alternatives and health-related services: We may use and disclose your information to tell you about alternative treatments or health-related services that may be of interest to you.
• Fundraising: We may use and disclose limited information about you to contact you in an effort to raise money for the Hospital. If you prefer not to receive such fundraising notices, you must notify our Privacy Officer in writing (see below).

Hospital patient directory: With your permission we may list limited information about you (name, room number, general condition such as “fair”) in our directory while you are a patient in the Hospital. We will give this information to anyone who asks for you. In this way family and friends can visit or check on your progress and florists can deliver flowers to you while the Hospital still keeps your medical information private. In addition, if you choose, you may provide us with your religious affiliation so that clergy – such as your priest, minister, or rabbi – can identify their congregants who are hospitalized.

Individuals involved in your care: With your permission we may release information about you to a family member or friend who is involved in your care. We may also release information about you to such an individual in a medical emergency.

Special Situations: In addition to the above, there may be times when we use or disclose your health information for the following reasons:

• As Required By Law: We will disclose health information about you when required to do so by federal, state, or local law.
• To Avert a Serious Threat to Health or Safety: We may use and disclose health 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. This may include disaster relief agencies.
• Research: We may use and disclose health information about you for officially-approved research as permitted by law, when a waiver of authorization is obtained from an Institutional Review Board or a Privacy Board, or through a limited set of information. Otherwise, we will only use or disclose your information for research with your specific authorization.
• Organ and Tissue Donation: If you are an organ donor, we may release health 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.
• Military and Veterans: If you are a member of the armed forces, we may release health information about you as required by military authorities.
• Workers’ Compensation: We may release health 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 health information about you for public health activities. These activities generally include the following: to prevent or control disease, injury, or disability, 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 an employer about a workforce member when necessary to evaluate a work-related illness or injury, when we notify you of this disclosure.
• Abuse, Neglect, or Domestic Violence: We may disclose health information about you to social service or government authorities if we believe you have been the victim of abuse, neglect, or domestic violence if you agree or if we are required by law and we believe it is necessary to prevent serious harm.
• Health Oversight Activities: We may disclose health 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 laws.
• Lawsuits and Disputes: We may disclose health information about you in response to a subpoena, discovery request, or other lawful order from a court.
• Law Enforcement: We may release health information if asked to do so by a law enforcement official as part of law enforcement activities; in investigations of criminal conduct or of victims of crime; in response to court orders; in emergency circumstances; or when required to do so by law.
• Coroners, Medical Examiners and Funeral Directors: We may release health 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.
• National Security: We may release health 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, or for intelligence, counterintelligence, and other national security activities authorized by law.
• Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health 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; (3) for the safety and security of the correctional institution.

OTHER USES OF MEDICAL INFORMATION
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 permission. If you give 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, thereafter we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You must 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 the health information about you:

Right to Inspect and Copy: You have the right to inspect and copy medical information that may be used by the Hospital to make decisions about you. Usually, this includes medical and billing records, but it 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 our Privacy Officer. If you request a copy of the information, we may charge a fee for the costs of copying and postage. We may deny your request to inspect and copy your information in certain very limited circumstances. If so, we will inform you of the denial, the reason for it, and how to request a review of the denial, if review is permitted by law. A licensed health care professional not involved with the denial will review your request and the denial. We will comply with the outcome of the review.

Right to Request Amendment: 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 is kept by the Hospital. To request an amendment, your request must be made in writing and submitted to our Privacy Officer. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it 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 created by another hospital or healthcare provider. But we will inform you of the source of that information if we know it. We may also deny your request if we believe the information is complete and accurate, and for other reasons as permitted by law.

Right to an Accounting of Disclosures: You have the right to an “accounting of certain disclosures.” This is a list or report of the disclosures we made of medical information about you for reasons other than your care, payment, and other Hospital purposes for which you did not sign an authorization. To request this list or accounting of disclosures, you must submit your request in writing to our Privacy Officer. Your request must state a time period that may not be longer than six years prior to the request date and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free. For additional lists during the same 12-month period, 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 the time before any costs are incurred. We may also provide a summary list as an option.

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 of your care, such as a family member or friend. 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 to our Privacy Officer. In your request, you must state (1) what use or disclosure you want to limit, (2) what information you want to limit, and/or (3) to whom you want the limits to apply.

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 our Privacy Officer. 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 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, please request one from our Privacy Officer or pick one up in your physician’s office or the Hospital’s Admitting Office.

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. The notice will contain the effective date in the top right-hand corner of the first page.

COMPLAINTS
If you believe your privacy rights have been violated or the Hospital is not in compliance with these privacy practices, you may file a complaint with the Hospital or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with us, call or write to our Privacy Officer whose contact information is below. All complaints must be submitted in writing. All complaints will be investigated by the Hospital. You will not be penalized in any way for filing a complaint. Complaints filed with the Secretary of Health and Human Services must be in writing and must be sent within 180 days of when you knew (or should have known) that the act or omission occurred. Send to U.S. Department of Health and Human Services, Office for Civil Rights, 200 Independence Avenue SW, Room 509 F, HHH Building, Washington D.C. 20201. Your letter must include the following points:

• The name of the hospital or provider; and
• A description of the acts or omissions that you believe are in violation of privacy requirements.

PRIVACY OFFICER
To request any of the above rights, or for further information about this Privacy Notice, please contact: Privacy Officer, Milford Hospital, 300 Seaside Avenue, Milford, CT 06460, Telephone: 203-876-4000