800 West 9th Street  Jasper, Indiana 47546
(812) 996-2345
Privacy Notice

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Your Privacy

This notice describes how Memorial Hospital and Health Care Center (the “Hospital”) may use and disclose collected information about you. It also explains how you can access this information. Please review it carefully. If you have any questions about this notice, please contact our designated Privacy Officer at (812) 996-0534 or e-mail concerns to:

“Protected Health Information” is:

  • Information about you that may identify you and
  • Relates to your past, present or future physical or mental health or condition, and/or
  • Health care services related to your health or condition.

Examples of this may include:

  • Your name, address, telephone number, and date of birth,
  • Your diagnosis (the condition for which you are receiving treatment),
  • Your treatment plan and goals, and
  • Your progress toward those goals.

In the rest of this notice, we will use “PHI” to mean “protected health information”.

This Notice of Privacy Practices describes how the Hospital may use and disclose (give to others) your PHI. We may use it to carry out treatment, obtain payment or in our health care business operations. We may also use it for other purposes that are permitted or required by law. This notice also describes your rights to see and control your PHI.

We are required to do what we say we will do in the Notice of Privacy Practices. We may revise our notice at any time. The new notice will cover all PHI that we keep at the time of the new notice. If you ask, we will give you the most current Notice of Privacy Practices. You can also get this information by going to our website: www.mhhcc.org

You can also call our hospital and ask us to send you a copy in the mail, or you can ask for one at the time of your next appointment.

Ways the Hospital May Use or Disclose Your PHI

The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures, we will explain what we mean and try to give some examples. Not every use of disclosure is a category that will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

  • Treatment: We will use and disclose your PHI when we are giving you services. We will also disclose your PHI when we are helping you get other services you need. This includes services you may get from another agency or person that already has your permission to use your PHI. For example, we would disclose needed parts of your PHI to a home health agency that gives you care. Also, we may disclose your PHI to another doctor or health care provider. This could be a specialist or laboratory that helps us with your treatment.
  • Payment: We will use the parts of your PHI needed to get payment for your health care services. Some of the reasons we would use your PHI are:
    • Finding out if your insurance will pay for the kind of service you are requesting,
    • Making sure services provided to you are medically necessary, and/or
    • Evaluating how we use various services.

For example, getting approval for a hospital stay may require that your PHI be released to your insurance company. We may need to give your health information about a surgery you received at the hospital so your health plan will pay us or reimburse you for the surgery.

  • Health Care Operations: We may use or disclose your PHI in order to support the business activities of the Hospital. These uses and disclosures are necessary to run the hospital and make sure that all of our patients receive quality care. These activities include such things as:
    • Making sure we meet important goals and standards,
    • Judging how well our employees do their job,
    • Training workers and volunteers,
    • Licensing or accreditation of our agency,
    • Marketing or fundraising, and
    • Carrying out other business activities.

For example, we may release your PHI to volunteers or interns who see patients at our Hospital. We may also use a sign-in sheet at the registration desk where you will be asked to sign your name, and/or call you by name in the waiting room. We may use or release your PHI, such as your name and address, to contact you to remind you of your appointment.

We will share your PHI with outside (“third-party”) “business associates” that perform different kinds of activities for our Hospital. For example, we might use an outside computer company to help us with our computer records. Whenever an arrangement like this involves the use or disclosure of your PHI, we will have a written contract with that organization that will protect your privacy.
We may use or release parts of your PHI to offer you information that may be of interest to you. For example, we may use your name and address to send you newsletters or other information about activities of our hospital. You may contact our Privacy Officer to ask that these materials not be sent to you.

  • 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 we feel may be of interest to you.
  • Hospital Directory: We may include certain limited information about you in the hospital directory while you are a patient at the hospital. This information may include your name, location in the hospital, your general condition (e.g., good, fair, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or pastor, even if they do not ask for you by name. This is so your family, friends and clergy can visit you in the hospital and generally know how you are doing.
  • Individuals Involved in Your Care or Payment for Your Care: We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition and that you are in the hospital. In addition, we may disclose medical information about you 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, state or local law.
  • 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.
  • Organ and Tissue Donation: If you are an organ donor, we may release medical 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 transportation.
  • Military and Veterans: 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.
  • Appointment Reminders: We may contact you to provide you with a reminder of any scheduled appointments.

Uses and Disclosures of Protected Health Information

You must give us special permission by signing a form called an authorization for any use or release of your PHI that is outside of treatment, payment or operations. You may cancel this authorization in writing at any time, unless our hospital has already released your PHI based on the authorization you gave us. The only time we would not need an authorization is if the use or release is permitted or required by state law. We will describe these situations below.

Other Permitted and Required Uses and Disclosures

We may use and release your PHI in the kinds of situations we describe below. You have the right to say how we can use or disclose your PHI. Your treating professional is allowed to use their professional judgment to decide if a use or release is in your best interest if you or you guardian are not present, or if you are not able either to agree or object to the use or release. In this case, only the PHI that is important for your health care will be released.

  • Emergencies: We may use or release your PHI in an emergency treatment situation. If this happens, we will try to get your consent as soon as possible after the delivery of treatment.
  • Communication Barriers: If you are an adult 18 years of age or older and do not have a guardian, we may use and release your PHI if someone at the hospital tries to get consent from you but cannot because of substantial communication barriers. “Substantial communication barrier” means that the person does not use any kind of speech, or other type of communication such as a body signal like blinking of the eyes for yes or no. If your treating professional determines, using professional judgment, that you intend to consent to this use or release under the circumstances, the following guidelines must be met:
  • A witness not employed by this hospital (preferably a family member or advocate) agrees that you cannot give consent, and
  • The witness signs a written statement agreeing that you were unable to give any type of consent and giving the reason why this is true.

Other Permitted and Required Uses and Releases Made Without Your Authorization

We may use or release your PHI in the following situations required by law without your authorization. You have a right to request an accounting from us of these disclosures.

  • Public Health: We may release parts of your PHI for public health purposes when the law requires us to do so. The release will only be made for the purpose of controlling disease, injury or disability.
  • Health Oversight: We may release your PHI to agencies that are responsible for making sure our services meet quality standards. They may need your PHI for activities such as audits, investigations, and inspections. Agencies that use this information include the Center for Medicare and Medicaid Services, the Indiana State Department of Health, etc.
  • Food and Drug Administration: We may release your PHI if the Food and Drug Administration requires it. This would be for the following reasons:
    • To report adverse events or product defects or problems, or
    • To help track products, or
    • To allow product recalls, or
    • To make repairs or replacements, or
    • To allow other types of product monitoring.
  • Legal Proceedings: We may release PHI in the course of any court or administrative proceeding, if we are ordered to do so, or to meet legal requirements.
  • Law Enforcement: We may also release PHI for law enforcement purposes. These may include:
    • Limited information requests for identification and location purposes related to victims of a crime, or
    • If there is suspicion that death has occurred as a result of a crime, or
    • In the event that a crime occurs on the property of the hospital, or
    • If there is a medical emergency not on the hospital’s property where it is likely that there has been a crime.
  • Coroners or Medical Examiners: We may release PHI to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties.
  • Research: We may release your PHI to researchers with your authorization. We may also release information to researchers when their research has been reviewed to make sure they will keep your PHI private.
  • Criminal Activity: If you tell your treating professional that you are going to harm another person we may release your PHI to the police and the person you threaten to harm.
  • Workers’ Compensation: We may release your PHI to comply with workers’ compensation laws and other similar programs.
  • Inmates: We may use or release your PHI if you are an inmate of a correctional facility and this agency created or received your PHI in the course of providing care to you.
  • Required Uses and Disclosures: We must release your PHI to the Department of Health and Human Services so they can make sure we are following the law (Section 164.500 et seq.).
  • Abuse and Neglect: We will release your PHI to the Indiana State Department of Health if we think there may have been child abuse or neglect, or vulnerable adult abuse or neglect. Federal and state laws require these reports. Indiana law does not require us to notify you when we make a report about abuse or neglect.

Your Rights

The following is a statement of your rights regarding your PHI and a brief description of how you may use these rights.

  • Right to Inspect and Copy: You have the right to inspect and copy your protected health care information. This means you may inspect and obtain a copy of PHI about you that is contained in a designated record set for as long as we maintain the PHI. “Designated record set”, means medical and billing records and any other records that this hospital uses for making decisions about you. Under federal law, however, you may not see a copy of the following records:
    • Psychotherapy notes,
    • Information we have gathered for use in court or at hearings,
    • PHI that is covered by a law that states you may not see it.

You may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about seeing or copying your medical record.

To inspect and copy the medical information included in your designated record set, you must submit your request in writing to the Director of Medical Records. If you request a copy of the information, we may charge a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We will normally provide you with access to this information within 30 days of your request.

  • Right to Request an Accounting of Disclosures: You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you.

To request this list or accounting of disclosures, you must submit your request in writing to the Hospital’s designated Privacy Officer. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically, etc.). The first list you request within a 12-month period will be free. 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.

We are not required to give you an accounting of information we have used or disclosed for purposes of treatment, payment or health care operations. We are not required to give you an accounting of information when we share information with our business associates. We are also not required to give you an accounting of our uses of PHI for which you have already given us written authorization.

  • Right to Request Restrictions: This means you may ask us not to use or release any part of your PHI for treatment, payment or health care operations purposes. You may also ask that any part of your PHI not be released to family members or others who may be involved in your care, or for other purposes as described in the Notice of Privacy Practices. You must tell us in writing what parts of your PHI you do not want released, and to whom you do not want it released.
    • To request restrictions, you must make your request in writing to the Hospital’s designated Privacy Officer. 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, for example, disclosures to your spouse.

We are not required to agree to your request. We will allow your PHI to be used or released if your treatment professional believes it is in your best interest. If your treatment professional does agree to your request, we may not use or release your PHI unless it is needed to provide emergency treatment. Please discuss any restriction you wish to request with your treating professional. You have the right to request to receive confidential communications from us by another means or at another location. For instance, you can ask us to send only mail from our office to your post office box instead of your home address. We will accommodate all reasonable requests. We will not ask you why you want this change. To request confidential communications, you must make your request in writing to the Hospital’s designated Privacy Officer.

  • Right to Amend Your PHI: You have the right to ask us to amend written information that we may have about you. We will generally amend your information within 60 days of your request and will notify you when we have amended the information. We are permitted by law to deny your request to amend your medical information in certain circumstances, like when we believe the information you have asked us to amend is incorrect. If you wish to request that we amend the medical information that we have about you, you must make you request in writing to the Hospital’s designated Privacy Officer.
  • You have the right to get a paper copy of this notice from us. 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. You may obtain a copy of this notice at any time at our website:

Changes to This Notice

The Hospital reserves the right to change the terms of this notice at any time, and the changes will be effective immediately and will apply to all protected health information that we maintain. We will post a copy of the most current notice in the hospital and on our web site. The notice will contain, on the first page, in the top right-hand corner, the version and effective date. You have a right to request a new version at any time.


You may complain to the Hospital or to the Secretary of the United States Department of Health and Human Services if you believe your privacy rights have been violated. You may file a complaint with the Hospital by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a complaint. All complaints must be submitted in writing.

You may contact our Privacy Officer at (812) 996-0534, 800-852-7279, ext. 534, or email:
for further information about the complaint process.

Other Uses of Medical Information

Other uses and disclosures of medical information not covered by this notice or the laws that apply to the Hospital will be made only with your written permission. If you provide the Hospital permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, the Hospital will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that the Hospital is 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.

This notice was published and became effective April 14, 2003.

HIPAA Privacy Officer
Memorial Hospital and Health Care Center
800 W. 9th Street
Jasper, Indiana 47546

Director Medical Records
Memorial Hospital and Health Care Center
800 W. 9th Street
Jasper, Indiana 47546