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.
If you have any questions about this notice, please contact:
Christy Stahl, HaysMed Privacy Officer
2220 Canterbury Drive, Hays, Kansas 67601
Office: (785) 623-2188 Cell: (785) 623-1821 Fax: (785) 623-5018 Hotline: (785) 623-2194
E-Mail: cstahl@haysmed.com

WHO WILL FOLLOW THIS NOTICE.
Hays Medical Center (HaysMed) provides health care to patients in partnership with physicians and other professionals and organizations. The information in this Notice of Privacy Practices will be followed by all the following entities, sites and locations of HaysMed:

• All individuals employed by HaysMed
• All hospital inpatient and outpatient departments
• Volunteers working at any HaysMed facility
• Medical, nursing, and other students present at any HaysMed facility
• Any health care professional who treats you at any HaysMed facility
• Center for Women's Health Clinic
• Dreiling/Schmidt Cancer Institute
• Graystone Cosmetic & Reconstructive Surgery Clinic
• Hays Family Medicine Clinic
• Hays Orthopaedic Clinic
• DeBakey Heart Clinic
• Hospice/Palliative Care/Lifeline
• Hays Psychological Associates Clinic
• High Plains Sports Medicine
• Medical Specialists Clinic
• Miller Medical Pavilion Pharmacy
• Nephrology Center of Western Kansas
• Neurology Clinic
• Pediatric Clinic
• Pulmonology Associates of Hays Clinic
• Southwind Surgical Clinic
• Western Kansas Urologicial Associates Clinic
• Work Smart Clinic

All these entities, sites and locations follow the terms of this notice. In addition, these entities, sites and locations may share your health information with each other for treatment, payment or health care operations as described in this notice.

DESPITE THE FOREGOING, THIS NOTICE IS NOT APPLICABLE TO THE FITNESS FACILITIES AT THE CENTER FOR HEALTH IMPROVEMENT, HAYSMED'S ATHLETIC TRAINING SERVICES PROVIDED AT SCHOOLS OR AT SCHOOL SPORTING ACTIVITIES, OR ANY PERSONNEL ASSOCIATED WITH THESE PROGRAMS.

OUR PLEDGE REGARDING HEALTH INFORMATION:

• Each time you visit a hospital, physician, or other healthcare professional, a record of your visit is made.
• Typically, this record contains your symptoms, examination, test results, diagnoses, treatment, a plan for your future care or treatment and billing-related information.
• Such records are necessary to provide you with quality care and to comply with certain legal requirements.
• Other health care professionals from whom you obtain care and treatment may have different policies or notices regarding the use and disclosure of your health information.
• We understand that your health information is personal.
• We are committed to protecting your health information.
• This notice will tell you about the ways in which we may use and disclose your health information. We also describe your rights and certain obligations we have regarding the use and disclosure of your health information.

WE ARE REQUIRED BY LAW TO:

• Make sure that health information that identifies you is kept private
• Give you this notice of our legal duties and privacy practices with respect to your health information
• Follow the terms of the notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
HaysMed may use and disclose your health information for the following purposes without your express consent or authorization. We will obtain your express, written authorization before using or disclosing your health information for any other purpose. You may revoke such authorization, in writing, at any time to the extent HaysMed has not relied on it.

Treatment

• We may use and disclose your health information to provide you with medical treatment or services at an HaysMed facility or other location.
• We may disclose your health information to doctors, nurses, technicians, students, or other hospital personnel who are involved in taking care of you at HaysMed. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietician if you have diabetes so that we may arrange for appropriate meals.
• Different departments of HaysMed may share your health information in order to coordinate the different things you need, such as prescriptions, lab work and x-rays.
• We also may disclose your health information to people outside HaysMed who may be involved in your medical care after you leave our facility, such as family members, friends or others who provide services that are part of your care.
• We may disclose your health information to other individuals (e.g., family members and friends) and health care providers involved in your medical care outside HaysMed's facilities.
• We may disclose your health information to other health care providers who request such information for purposes of providing treatment to you.

Payment

• We may use and disclose you health information to obtain payment for goods and services we provide to you. For example, we may disclose your health information to your health plan to obtain payment from that plan.
• We may disclose your health information to a thirty-party payor to receive prior approval or to determine whether the third-party payor will provide coverage for specific goods or services.
• We may disclose your health information to your family members and friends involved in the payment for goods and services provided to you.
• We may disclose your health information to other health care providers who request such information for purposes of obtaining payment for goods and services they provide.

Health Care Operations

• We may use and disclose your health information for our internal operations including, but not limited to, quality assessment and improvement activities; accreditation, certification, licensing or credentialing activities; conducting or arranging for medical review, legal services, and auditing functions; business management and general administrative activities; and business planning and development.
• We may also combine health information about many patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective.
• We may also disclose information to doctors, nurses, technicians, students, and other hospital personnel for review and learning purposes.
• We may also combine the health information we have with health information from other hospitals to compare how we are doing and see where we can make improvements in the care and services we offer.
• We may disclose your health information to other health care providers or health plans with which you also have had a relationship for purposes of that provider's or plan's internal operations.

Appointment Reminders and Telephone and E-mail Messages
We may use and disclose your health information to provide you with appointment reminders. This may include contacting you with the date, time and location of your appointment by (1) sending a reminder card to the most recent mailing address we have for you; (2) sending an e-mail message to the most recent e-mail address we have for you; or (3) calling the most recent telephone number we have available and, if necessary, leaving a voice mail message or a message with a person other than you who answers your telephone number. If we need to contact you for a reason other than an appointment reminder (e.g., to report test results), we may send or leave a message asking you to contact us. We will not leave any additional information, unless you direct us otherwise in a particular circumstance.

Surveys
We may use and disclose health information to conduct surveys to assess your satisfaction with our services. We may send such survey to you by regular mail or by sending a message to the most recent e-mail address we have for you.

Treatment Alternatives and Health-Related Benefits and Services
We may use and disclose health information to tell you about or recommend possible treatment options or alternatives, to tell you about health-related benefits or services that may be of interest to you, or to provide you with promotional gifts of nominal value. We may communicate such information face-to-face, by regular mail, or by sending a message to the most recent e-mail address we have for you.

Fundraising Activities
Contributions to the Hays Medical Center Foundation are used to expand and improve the services and programs we provide the community. To inform you of opportunities to support the Medical Center, we may disclose to the Foundation basic demographic information about you (such as name and contact information) and the dates you were treated. No information concerning your medical condition or treatment you received will be disclosed to the Foundation. If you do not want to be contacted for fundraising efforts, please write the Hays Medical Center Foundation, 2220 Canterbury Drive, Hays, KS 67601.

Business Associates
There are some services provided in our organization through contracts or arrangements with business associates. For example, we may contract with a copy service to make copies of your health record. When these services are contracted, we may disclose your health information to our business associate so they can perform the job we have asked them to do. To protect your health information, however, we require our business associates to appropriately safeguard your information.

Hospital Directory
We may include certain limited information about you in the hospital directory while you are a patient at HaysMed. This information may include your name, location in the hospital, your general condition (e.g., fair, stable, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may also be released to people who ask or you by name.

Research

• Under certain circumstances, we may use and disclose health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process which evaluates a proposed research project and its use of health information, trying to balance the research needs with patient privacy interests.
• Before we use or disclose health information for research, the project will have been approved through this research approval process. We may disclose your health information to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the health information does not leave HaysMed's facilities.

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.

SPECIAL SITUATIONS:
Organ and Tissue Donation
If you are an organ donor, we may disclose your 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 disclose your health information as required by military command authorities. We may also disclose health information about foreign military personnel to the appropriate foreign military authority.

Employers

• We may disclose your health information to your employer if we provide health care services to you at the request of your employer, and the health care services are provided either to conduct an evaluation relating to medical surveillance of the workplace or to evaluate whether you have a work-related illness or injury. In such circumstances, we will give you written notice of such disclosure of information to your employer.
• Any other disclosures to your employer will be made only if you sign a specific authorization for the disclosure of that information to your employer.

Worker's Compensation
We may disclose your health information for worker's compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks
We may disclose your health information for public health activities. These activities generally include the following:

- to prevent or control disease, injury or disability;
- to report births and deaths;
- 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 the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make the disclosure if you agree or when required or authorized by law.

Health Oversight Activities
We may disclose your 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 rights laws.

Lawsuits and Disputes

• If you are involved in a lawsuit or a dispute, we may disclose your health information in response to a court or administrative order.
• We may also disclose your health information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Disaster Relief
We may disclose your health information to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.

Law Enforcement
We may disclose your health information if asked to do so by a law enforcement official:

- In response to a court order, subpoena, warrant, summons or similar process;
- To identify or locate a suspect, fugitive, material witness, or missing person;
- About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
- About a death we believe may be the result of criminal conduct.
- About suspected criminal conduct at HaysMed's facilities;
- In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners, and Funeral Directors

• We may disclose your 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 information about patients of HaysMed to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities
We may disclose your health information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others
We may disclose your health information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state, or to conduct special investigations.

Inmates/Persons in Custody
If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your health information to the correctional institution or law enforcement official if such disclosure is necessary (1) for the institution to provide you with healthcare; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION:
You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy

• You have the right to inspect and copy health information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.
• To inspect and copy your health information, you must complete a specific form providing information we need to process your request. To obtain this form or to obtain more information concerning this process, please contact the HaysMed Health Information Management Department at (785) 623-5827. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies and services associated with your request. We may require that you pay such fee prior to receiving the requested copies. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional chosen by HaysMed will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend

• If you believe that health 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 or for HaysMed. To request an amendment, you must complete a specific form providing information we need to process your request, including the reason that supports your request. To obtain this form or to obtain more information concerning this process, please contact the HaysMed Health Information Management Department at (785) 623-5827. We may deny your request for an amendment if you fail to complete the required form in its entirety. In addition, we may deny your request if you ask us to amend information that:

  - Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  - Is not part of the health information kept by or for HaysMed.
  - Is not part of the information which you would be permitted to inspect and copy; or
  - Is accurate and complete.

• If your request is denied, you will be informed of the reason for the denial and will have an opportunity to submit a statement of disagreement to be maintained with your health records.

Right to an Accounting of Disclosures
You have the right to request an "accounting of disclosures." This is a list of the disclosures we may make of health information about you, with certain exceptions specifically defined by law. To request this list or accounting of disclosures, you must complete a specific form providing information we need to process your request. To obtain this form or to obtain more information concerning this process, please contact the person identified on the first page of this Notice. 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). 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.

Right to Request Restrictions

• You have the right to request a restriction or limitation on the health 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 health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.
• 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 emergency treatment.
• To request restrictions, you must complete a specific form providing information we need to process your request. To obtain this form or to obtain more information concerning this process, please contact the HaysMed Health Information Management Department at (785) 623-5827.

Right to Request Alternative Methods of 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 alternative methods of communications, you must complete a specific form providing information we need to process your request. To obtain this form or to obtain more information concerning this process, please contact the person identified on the first page of this Notice. 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. To obtain a paper copy of this notice, contact the person identified on the first page of this notice.
• You may obtain a copy of this Notice at our website: www.haysmed.com

Your Rights Regarding Electronic Health Information Exchange

• HaysMed participates in electronic health information exchange, or HIE. New technology allows a provider or a health plan to make a single request through a health information organization, or HIO, to obtain electronic records for a specific patient from other HIE participants for purposes of treatment, payment, or health care operations. HIOs are required to use appropriate safeguards to prevent unauthorized uses and disclosures.
• You have two options with respect to HIE. First, you may permit authorized individuals to access your electronic health information through an HIO. If you choose this option, you do not have to do anything.
• Second, you may restrict access to all of your information through an HIO (except access by properly authorized individuals as needed to report specific information as required by law). If you wish to restrict access, you must complete and submit a specific form available at http://www.khie.org. You cannot restrict access to certain information only; your choice is to permit or restrict access to all of your information.
• If you have questions regarding HIE or HIOs, please visit http://www.khie.org for additional information.
• Even if you restrict access through an HIO, providers and health plans may share your information directly through other means (e.g., facsimile or secure e-mail) without your specific written authorization.
• If you receive health care services in a state other than Kansas, different rules may apply regarding restrictions on access to your electronic health information. Please communicate directly with your out-of-state health care provider regarding those rules.

Breach Notification.
We are required to provide you with written notice concerning any breach of your health information. You will receive such notice via first-class mail, unless you agree to an alternative form of notice, or we do not have a current address for you. If you have any concerns regarding any possible unauthorized use or disclosure of your health information and/or any breach notification made by HaysMed, you should contact HaysMed's Privacy Officer immediately.

Right to File a Complaint.
If you believe your rights with respect to health information have been violated by HaysMed, you may file a complaint with HaysMed or with the Secretary of the Department of Health and Human Services. To file a complaint with HaysMed, contact HaysMed's Privacy Officer. Complaints should be submitted in writing.

You will not be penalized for filing a complaint.

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 health 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 at our facility and on our website. The notice will contain the effective date on the first page.

ACKNOWLEDGEMENT
You will be asked to provide a written acknowledgement of your receipt of this Notice. We are required by law to make a good faith effort to provide you with our Notice and obtain such acknowledgement from you. However, your receipt of care and treatment from HaysMed is not conditioned upon your providing the written acknowledgement.

7/2012