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BLESSING SYSTEM NOTICE OF PRIVACY PRACTICES – Effective June 4, 2015

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.

This privacy notice will be used by the following Blessing System organizations (“The Blessing System”) including, Blessing Corporate Services, Inc., Blessing Hospital, Blessing Corporate Services, Inc. d/b/a Blessing Physician Services, BlessingCare Corp d/b/a Illini Community Hospital, Illini Health Services, LLC, Denman Services, Inc., and Hannibal Medical Supplies, LLC.

In addition, Blessing Hospital will use this Notice as a joint notice with Cogent Healthcare, Quincy Anesthesia Associates, P.C, SIU School of Medicine physicians practicing at East Adams Clinic, West Central Pathology Specialists, S.C., Tri-State Radiation Oncology, PC and Clinical Radiologists, S.C. Illini Community Hospital will use this Notice as a joint notice with Clinical Radiologists, S.C. Blessing Corporate Services will use this as a joint notice with Quincy Medical Group physicians practicing at the Hamilton/Warsaw and the Palmyra Clinics and with SIU School of Medicine physicians practicing at the Quincy Sports and Occupational Medicine Program.

I understand that the hospital has decided to use a Joint Notice of Privacy Practices and a Joint Acknowledgment Form with independent physicians or physician groups relating to federal and state privacy rights and protections for patients which are further described in this Joint Privacy Notice. Discharge documentation from the Hospital to the ambulatory record will be shared.

I further understand, acknowledge and agree that the use of a Joint Notice and Acknowledgment Form, as part of an organized health care arrangement, rather than the use of separate notices and forms under these laws is being done only for my convenience as a patient and to improve access to the delivery of health care services. Finally, I understand, acknowledge and agree that the physicians are and still remain independent contractors and are not agents, servants or employees of the hospital and are solely responsible for their judgment and conduct in treating or providing professional services to me and for their compliance with state and federal privacy laws. Nothing in this privacy notice is meant to imply, infer or create any agency or employment relationship between the physicians and the hospital, either actual or implied, nor is this privacy notice intended to alter or limit any other consents for treatment or procedures I may sign during the time I am provided care at this facility.

Your Rights

Federal and state law protects your right to keep your individually identifiable health information private.  You may request that you receive communications from The Blessing System regarding individually identifiable health information by alternative means or at alternative locations.  You must make your request for confidential communications in writing and must submit this request to the office listed below.

The Blessing System reserves the right to condition your request on the receipt of information regarding how you desire The Blessing System to handle payment and/or on the availability of an alternative address or method of contact that you may request.  You may request other restrictions on certain uses and disclosures of protected health information for purposes of treatment, payment, and health care operations; however, the law does not require The Blessing System to agree to the requested restrictions unless the restriction request is a reasonable restriction on communication

You generally have the right to inspect and obtain a copy of any individually identifiable health information in your medical record in the form and format in which you request it, including electronically if readily producible in the requested format within thirty (30) days of our receipt of your written request, unless extended by agreement to sixty (60) days, with the exception of psychotherapy notes, information compiled in anticipation of use in a civil, criminal, or administrative proceeding and certain other health information which the law restricts The Blessing System from disseminating.  However, if you are a patient of certain types of providers or facilities, you may have a right to access your patient records or information on an unqualified basis.  Specifically, the following:

·         If you are a patient at a facility that performs mammograms, you have the right to access your original mammograms and copies of your patient reports on an unqualified basis. 

·         If you are a patient of a hospital, you have the right to access your patient records on an unqualified basis, upon written request. 

·         If you are a patient of a physician, you have the right to access your medical data on an unqualified basis upon request.

·         If you are a resident of a skilled nursing facility, you have the unqualified right to obtain from your physicians, or the physicians attached to the facility, complete and current information concerning your medical diagnosis, treatment and prognosis in terms and language that you can reasonably be expected to understand.  You, and your guardian or representative or parent if you are a minor, also have the unqualified right to inspect and copy your medical records that the facility or your physician maintains.

·         If you are a recipient of mental health or developmental disabilities services and if you are age 12 or older, you have an unqualified right to inspect and copy your records.  The following persons also have this right:  (i) your guardian if you are age 18 or older; (ii) an appointed agent under a power of attorney for health care which authorizes record access; (iii) your parent or guardian if you are under age 12; (iv) your parent or guardian if you are, at least, age 12 but under age 18 and if certain conditions are satisfied; and (v) a guardian ad litem representing you in any judicial or administrative proceeding if you are age 12 or older.

·         You also have the right to amend your individually identifiable health information, unless The Blessing System did not create such information or unless The Blessing System determines that your medical record is accurate and complete in its existing form.

·         You have the right to request and receive an accounting of disclosures of your individually identifiable health information that The Blessing System has made in the three (3) years prior to the request date.  Such an accounting may not include disclosures made to carry out treatment, payment or health care operations, to create an accurate patient directory or notify persons involved in your care, to ensure national security, to comply with the authorized requests of law enforcement, or to inform you of the content of your medical records. 

·         You have the right to request that The Blessing System restrict disclosure of your individually identifiable health information to a health plan for the purpose of carrying out payment or health care operations, if not otherwise required by law, if the information pertains solely to a health care item or service for which you or someone on your behalf, other than the health plan, has paid The Blessing System in full.

·         You have the right to request that a copy of your individually identifiable health information be transmitted directly to another person designated by you as long as this request is made in writing, signed by you and clearly identifies the person to receive this information and where the copy is to be sent.

·         You have the right to receive a notification in the event that The Blessing System becomes aware that your unsecured individually identifiable health information has been impermissibly used or disclosed unless it has determined that there has been a low probability that the information has been compromised after conducting a risk assessment.  If you would like more information on how to exercise these rights, please contact The Blessing System’s Privacy Officer at (217) 223-8400, Extension 6808.

Grievances or further inquiries

If you believe that The Blessing System has violated your privacy rights with respect to individually identifiable health information, you may file a complaint with The Blessing System and the Department of Health and Human Services. To file a complaint with The Blessing System, please contact the Blessing Corporate Services Vice President, Corporate Compliance and Organizational Planning (the person assigned Privacy Officer responsibility) at 217-223-8400, Extension 6808.  The Blessing System will not retaliate against you for filing a complaint.  You may also contact the above office for a copy of this Privacy Notice or for further information regarding its contents.