Notice of Privacy Rights and Practices
Version 5 Effective: September 9, 2013



1. Respectful and safe care given by competent personnel
2. Be informed of patient rights during the admission process
3. Be informed in advance about care and treatment and of any change
4. Participate in the development and implementation of a plan of care and any changes
5. Make informed decisions regarding care and to receive information necessary to make decisions
6. Refuse treatment and to be informed of the medical consequences of refusing treatment
7. Formulate advance directives and to have the hospital comply with the directives unless the hospital notifies the patient of the inability to do so
8. Personal privacy and confidentiality of medical records
9. Be free from abuse, neglect and exploitation
10. Access information contained in his/her medical record within a reasonable time frame when requested, subject to limited circumstances where the attending physician determines it would be harmful to disclose the information to the patient for therapeutic reasons
11. Be free from chemical and physical restraints that are not medically necessary
12. Receive hospital services without discrimination based upon race, color, religion, gender, national origin, or payer. Hospitals are not required to provide uncompensated or free care and treatment unless otherwise required by law
13. Voice complaints and file grievances without discrimination or reprisal and have those complaints and grievances addressed


-> All FCH employees, medical students, residents, therapists, volunteer groups, and other personnel whether paid or not, also known as the "workforce"
-> All independent healthcare providers joined in FCH Organized Health Care Arrangement (OHCA), as described below:
All "workforce" and independent healthcare providers will follow the terms of this Notice. In addition, the "workforce" and independent healthcare providers may share medical information with each other for your treatment, payment and healthcare operations described in this Notice.

FCH is required to:

-> Protect the privacy of your health information, provide you with a current copy of the Notice of Privacy Rights and Practices and display the most current copy of the Notice on our website:
-> Do what we say we will do in this Notice
-> Notify you if we are unable to agree to your written requests. FCH will honor patient requests whenever possible.

We have the right to change this Notice and our policies and procedures and apply it to the health information we already have about you and any we receive in the future.


Independent healthcare providers who belong to the Fillmore County Hospital Medical Staff must be able to share health information freely for treatment, payment and healthcare operations. This Notice also serves as the Joint Notice of Privacy Rights and Practices of FCH and eligible members of this medical staff who participate in OCHA. Under this arrangement, FCH and these medical staff members agree to follow the health information practices described in this Notice when using or disclosing FCH records and information related to FCH visits. Under the OCHA, each provider will:
- Use, distribute and follow the health information practices in this Notice of Privacy Rights and Practices.
- Obtain a single signed acknowledgment of receipt
- Share health information from inpatient and outpatient FCH visits among medical staff members

**This Notice does NOT cover the health information practices or health information of medical staff members in their private offices or at other practice locations.**


FCH is committed to protecting your health information. In order to provide you with quality care and to comply with certain legal requirements; we create a record of the care and services you receive each time you visit FCH. Your medical record may include your symptoms, what was found during exams, tests results, diagnoses, treatment given and a future plan of care.

Although your medical and financial records are the property of FCH, the information belongs to you. FCH complies with all Federal and State laws that apply. All request to exercise the following health information rights must be in writing. We will follow policies to handle requests and notify you of our actions and your rights. You may receive request forms or exercise your right by contacting the FCH Privacy Officer, Abby Tuberville, at 402-759-3167.

-> Request Restrictions: You have the right to request a restriction on how we use and disclose your health information for treatment, payment, healthcare operations or to certain family members or friends identified by you who are involved in your care or payment for your care. We are not required to agree to your request and we will notify you if we are unable to agree.
-> Access your Health Information: You have the right to request to inspect and/or receive a copy of your health information. If you request copies, we may charge you a copying fee.
-> Amend/Correct your Health Information: You have the right to request that we amend or correct your health information that we keep in your record. We are not required to make all requested amendments, however we will give each request careful consideration. If we deny your request, we will provide you with a written explanation of the reason and your rights.
-> Confidential Communication: You have the right to request that we communicate with you about your health information in a certain way or at a certain location. We will accommodate your request if it is reasonable and specifies the alternate means of location.
-> Obtain an Accounting of Disclosures: You have the right to receive an accounting of disclosures of your health information made by us or our business associates. The first accounting in any 12 month period is free; you will be charged for each subsequent accounting you request within the same 12 month period.
-> Change your Mind: You have the right to change your mind about sharing your health information except for what has already been shared.


The following are the types of uses and disclosures FCH may make of your health information without permission. Where State law restricts one of these uses or disclosures, we will follow State law. These are general descriptions only and do not cover every example of use and disclosure.


We will use your health information for TREATMENT purposes. For example:
- We will use and disclose your health information to nurses, physicians and technicians who are involved in your care at FCH. Information obtained will be maintained in your medical record and used to determine the treatment that should work best for you.
- We will provide any facility or provider involved in your care with information that may assist in your treatment.
- When you are no longer receiving care at FCH, we will provide information to any healthcare provider that cares for you. These copies of your medical record help them continue your plan of care after discharge.


We will use your health information for PAYMENT purposes. For example:
- We will send a bill to you and/or your insurance company. The information may include your name, diagnosis, procedures, and supplies used.
- We will provide needed information to other healthcare providers for their billing purposes. For example, if you are brought in by ambulance, the information collected will be given to the ambulance provider for their billing purposes.


We will use your health information for the OPERATION of FCH. For example:
- FCH staff members may use information in your medical record to assess the results of your care. This information is used to improve the services we provide.
- FCH may share your health information with other healthcare providers for their operations if they have or had a relationship with you. The ambulance company, for example, may want information on your condition to help them know whether they have done an effective job of stabilizing your emergency condition.

Hospital Directory

Unless you tell us otherwise, we may provide information about you in the hospital directory while you are a patient. This information may include your name, location and general condition in terms that do not communicate specific medical information about you. The directory information may also be released to people who contact the hospital and ask for you by name. Your name and religious affiliation may be given to a member of the clergy, such as a priest or minister, even if they do not ask for you by name. This is so your family, friends and the clergy may visit you in the hospital. * Notify us immediately upon admission if you do NOT want us to list you on our hospital directory.*

Family, Friends, Others Involved in Your Care

We may give your health information to individuals involved in your care or payment for your care, this may include a family member, friend or any other person identified by you as being involved in your medical care or who is involved in the payment of your care. We will only release this information if you agree to the disclosure, are given the opportunity to object to such a disclosure and do not, or if in our professional judgment it is in your best interest to allow a person to act on your behalf, such as in an emergency situation when you are incapacitated. For example, we may allow a family member to pick up your x-rays, medical supplies or a prescription; or we may give them health information regarding how to care for you when you return home. We may also disclose your information to an organization assisting in disaster relief efforts (i.e. Red Cross) so that your family or individual responsible for your care can be told about your condition and location.

Incidental Uses and Disclosures

We are not required to eliminate every risk of an incidental use or disclosure of your health information. There are certain incidental uses or disclosures of your information that occur while we are providing services to your or conducting or business, these types of disclosures are permitted as long as the information being shared is limited to the "minimum necessary". For example, we need to use your name to identify you or your family members while waiting in our waiting area. Other individuals waiting in the same area may hear your name called.

Appointments & Treatment Alternatives

We may call you about appointments or treatment alternatives or other health-related benefits and services that may be of interest to you. For example, to speed up your registration, we may call ahead for information and/or to remind you of appointments. Or we may provide you with information regarding a health management program that we provide for diabetics.

Business Associates

People or companies, known as business associates, who are not employed by us, provide some services. We will allow our business associates to use your health information if needed. FCH requires business associates to protect patient's health information. For example, we may send your health information to a billing services so that they can help us bill for services.


Under certain circumstances, we may use or disclose your health information for research. For example, we may disclose information to researchers when their research has been approved by a special committee that has reviewed the research proposal and ensure they privacy of your health information. FCH approved research includes your health information on with your written permission.

Deceased Individuals

We will provide your health information to funeral directors as needed, and to coroners or medical examiners to identify a deceased person, determine the cause of death, or to perform other functions authorized by law.

Organ, Eye or Tissue Donation

We will share your health information with organ transplant organizations. For example, following State law, we will share health information with organizations or groups to facilitate the donation and transplantation of organs, eyes and tissue.

Public Health

We will share health information about you to assist public health activities or as required by law. These activities may include disclosures to:
- A public health authority authorized by law to collect or receive information for the purpose of preventing or controlling disease (i.e. cancer or West Nile), injury or disability (i.e. head trauma)
- Appropriate authorities authorized to receive reports of child abuse, neglect or domestic violence
- Report reactions to medications or problems with faulty products
- Notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition
- Employers, regarding employees, when requested by the employer, for health information concerning a work-related injury or illness.

Worker's Compensation

We will disclose your health information as authorized by law for worker's compensation or similar programs that provide benefits for work-related injuries or illness. For example, if you are injured on the job, we will share medical information about you to your worker's compensation representative.

Law Enforcement

We will provide certain health information if asked to do so by a law enforcement official. For example, we will share your health information as needed:
- As required by law in response to a court order, subpoena, warrant, summons, or similar process
- To identify or locate a suspect, fugitive, material witness, or missing person
- In response to a law enforcement officials request for information about a victim or suspected victim of a crime
- To alert law enforcement of a person's death if we suspect criminal activity caused the death
- When health information is evidence of a crime that occurred at FCH
- In an emergency to report a crime; the location of the crime or victims; or identify, discretion or location of the person who committed the crime
- To prevent or lessen a serious and imminent threat to a person or the public

Healthcare Oversight Activities

We may disclose your health information to health oversight agencies for activities authorized by law. These oversight activities include, for example, audits, investigations and inspections necessary for the oversight of the healthcare system and government benefit programs (i.e. Medicare, Medicaid).

Judicial and Administrative Proceedings

We may disclose your health information for judicial or administrative proceedings as required or permitted by law or in response to a valid subpoena, court order or other binding authority.

Correctional Institutions

If you are an inmate or in the custody of law enforcement, your health information may be disclosed to the correctional institution, its agents or law enforcement official to provide you with health care; to protect your health and safety; to protect the health and safety of others; and to assist in the safety and security of the correctional institution.

Essential Government Functions

We may disclose your health information for certain essential government functions. Such functions include: conducting intelligence and national security activities authorized by law; and providing protective services to the President or other authorized persons.


The following are types of uses and disclosures that require your written authorization. These are general descriptions only and do not cover every example of use and disclosure. (45 C.F.R. § 164.520). Any uses or disclosures other than those expressly permitted by the Privacy Rule will be made only with the written authorization of an individual. (45 C.F.R. § 164.520). The following uses and disclosures will be made only with your authorization:
1. Most uses and disclosures of psychotherapy notes (if we record them)
2. Uses and disclosures of PHI for marketing purposes, including treatment communications
Media Use We are required to obtain specific written authorization from you to disclose your photo and/or story outside the facility (i.e. to the media). We may ask to take photos of you during special occasions. For example: special events or activities, i.e. new babies born at FCH; or testimonials for paper and website. Only information authorized by you will be used.
Fundraising We may ask you to use your health information for fundraising activities. For example, we may ask to use and disclose certain elements of your health information, such as your name, address, phone number and dates you received treatment or services, to a business associate or a foundation related to FCH so that they may contact you to raise money for the hospital and its operations. *If you do not want to be contacted for fundraising efforts you must contact the hospital in writing.* (45 C.F.R. § 64.520(b)(1)(iii)(B)) 3. Disclosures that constitute a sale of PHI
4. Other uses and disclosures not described in this notice.


You have the right to be notified of a breach of your unsecured protected health information. We will notify you in written form by first-class mail, or alternatively, by e-mail if you have agreed to receive such notices electronically. If we have insufficient or out-of-date contact information for 10 or more individuals affected, we will provide substitute individual notice by either posting the notice on the home page of our website or by providing the notice in major print where noticeable. If we have insufficient or out-of-date contact information for 10 or less individuals affected, we will provide substitute notice by an alternative form or written, telephone or other means. You will be notified no later than 60 days following the discovery of a breach and will be informed of the extent of the breach, information involved in the breach, steps you should take to protect yourself from potential harm, and brief description of what we are doing to investigate the breach, mitigate the harm, and prevent further breaches, as well as contact information for us.


If you have questions with regard to the contents of this Notice or would like additional information, you may contact the FCH Privacy Officer at 402-759-3167 or 1-877-277-9771.

Complaints or questions about your privacy rights must be made in writing to the Privacy Officer at Fillmore County Hospital, P.O. Box 193, 1900 F St., Geneva, NE 68361.

If you believe your privacy rights have been violated, you have the right to file a complaint in writing with the Secretary of Health and Human Services. Nothing will be held against you for filing a complaint.