OUR PLEDGE REGARDING YOUR MEDICAL INFORMATION:

Our organization is dedicated to maintaining the privacy of your medical information. We create a record of the care and services you receive to provide quality care and to comply with legal requirements. This notice applies to all of the records of your care that we maintain, whether created by our staff or your personal doctor. Your personal doctor may have a different notice regarding the doctor’s use and disclosure of your medical information created in his/her office.

These records are our property. However, we are required by law: ? To keep medical information about you private. ? To give you this notice of our legal duties and privacy practices concerning your medical

information. ? To follow the terms of the Notice of Privacy Practices that is currently in effect.

WHO WILL FOLLOW THIS NOTICE:

? Any health care professional who treats you at any of our locations.

? All departments and affiliates of our organization, including:

• Floyd Medical Center • Floyd Primary and Urgent Care Locations
• Floyd EMS • Heyman HospiceCare at Floyd
• Floyd Home Care Services • Family Practice Residency Center
• Floyd Behavioral Health Center • All other Floyd Outpatient and Ancillary Departments

? All employed associates, staff or volunteers of our organization, including any of the locations or affiliates listed above. This includes the physicians on our medical staff and any contracted individuals or groups we allow to help you with your care within the Floyd Medical Center Health System (FMC). Because Floyd is a teaching institution, this also includes medical residents or medical students, nursing students, or students in other health care professions.

CHANGES TO THIS NOTICE:

The terms of this notice apply to all records containing your medical information that are created or retained by us. We reserve the right to revise, change, or amend our Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of the information that we may receive, create, or maintain in the future. Our organization will post a copy of our current notice in our offices in a prominent location, and you may request a copy of our most current notice during any visit to our organization.

HOW WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION:

The following categories describe the different ways in which we may use and disclose your medical information. Please note that not every particular use or disclosure is listed below but does fall within one of the categories.

Without your written authorization, we may use your health information for the following

purposes:

? Treatment – For example, a doctor may use the information in your medical record to determine which treatment option, such as an operation or a drug, best addresses your health needs.

? Payment – Our organization may use and disclose your medical information in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits. We may also use your information to coordinate payment arrangements with insurers or others responsible for your bill.

? For Health Care Operations – Our organization may use and disclose your medical information to operate our business. These uses and disclosures are important to ensure that you receive quality care and that our organization is well run. For example, we may use or disclose your information for quality improvement, business management, or teaching purposes.

THE FOLLOWING CATEGORIES DESCRIBE ADDITIONAL CONDITIONS IN WHICH

WE MAY USE OR DISCLOSE YOUR MEDICAL INFORMATION:

? Facility Directory – If you are an inpatient at Floyd Medical Center, we may include limited information about you in our facility directory. This information is limited to your name, location in the hospital, and a general statement about your condition, such as “stable” or “critical.” The directory information may be released to people who ask for you by name. If you do not want your information included in our directory, when you are admitted you should inform the person who registers you that you wish to be designated as a “No Information” patient. Please be aware that if you choose this designation, we cannot inform any visitors or callers of your hospital stay, and you will not be able to receive any mail or floral deliveries. There is no publicly available facility directory at Floyd Behavioral Health Center. All Floyd Behavioral Health Center patients are treated as “No Information” patients.

? Health-Related Use and Disclosure – Our organization may use and disclose your medical information to remind you that you have an appointment, or to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you.

? Fundraising – FMC may provide the Floyd Healthcare Foundation with personal information for fundraising purposes. This information will be limited to demographic information and dates of treatment. For example, each year we sponsor a “Love Light Tree” and may invite you to contribute a gift to put an ornament on the tree in your name or the name of a loved one.

? Required by Law – We will use or disclose medical information about you when required by law.

? Public Health Activities – Our organization may disclose your medical information for public health purposes. Examples include:

• to prevent or control disease, injury or disability;
• to maintain vital records, such as births and deaths;
• to report abuse or neglect as required by law;
• to notify a person regarding potential exposure to a communicable disease;
• to notify a person regarding a potential risk for spreading or contracting a disease or condition;
• to report reactions to drugs or problems with products or devices;
• to notify individuals if a product or device they may be using has been recalled;
• to notify your employer under limited circumstances, related primarily to workplace injury or illness or medical surveillance.

? Health Oversight Activities – Our organization may disclose your medical information to a health oversight agency for activities authorized by law, such as investigations, inspections, audits, surveys, licensure and disciplinary actions.

? Lawsuits and Similar Proceedings – Our organization may use and disclose your medical information in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We may also disclose your medical information in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, to the extent such disclosure is legally required.

? Law Enforcement – We may release medical information to law enforcement officials:

• regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement;
• concerning a death we believe might have resulted from criminal conduct;
• regarding criminal conduct on our premises;
• identifying/locating a suspect, material witness, fugitive or missing person; and
• in an emergency, reporting a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator).

? Business Associates – We may share your medical information with “business associates” that perform such services as chart audits for us through contracts that we have with them. These contracts contain terms that are intended to safeguard the privacy of your medical information.

? Others Involved in Your Healthcare – Unless you object, we may disclose to a family member, a relative, a close friend, or any other person that you identify, your medical information that directly relates to that person’s involvement in your care or with payment related to your care. If you are not able to agree or object to a disclosure, we will use our professional judgment regarding such disclosure.

? Release of Medical Information to Plan Sponsor – For those individuals who are insured by Floyd Healthcare Management Inc. Group Health Plan, our organization may disclose medical information to the plan sponsor.

? Coroners, Medical Examiners, and Funeral Directors – Our organization may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to 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.

? Organ and Tissue Donation – We may use or disclose your medical information to organizations that handle organ and tissue procurement, banking, or transplantation.

? Research – Under certain circumstances, we may use and disclose medical information about you for research purposes. All research projects, however, are subject to a special approval process. We may disclose medical information about you to people preparing to conduct a research project, so long as the medical information they review does not leave our premises.

? Serious Threat to Health or Safety – Our organization may use and disclose your medical information when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public.

? Specialized Government Functions – Our organization may disclose your medical information if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate military command authorities. In addition, our organization may disclose your medical information to federal officials for intelligence and national security activities authorized by law. We also may disclose your medical information to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations. Furthermore, our organization may disclose your medical information to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official.

? Health Fairs – We may use your personal information collected at health fairs for internal business management purposes.

? Workers’ Compensation – Our organization may release your medical information to your employer and/or its insurance carrier respecting Workers’ Compensation claims and similar programs.

YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION:

Requesting Restrictions – You have the right to request a restriction in our use or disclosure of

your medical information for treatment, payment or health care operations. We are not required

to agree to your request. In order to request a restriction in our use or disclosure of your

medical information, you must make your request in writing, and must describe in a clear and

concise fashion: (1) the information you wish restricted; (2) whether you are requesting to limit

our use, disclosure or both; and (3) to whom you want the limits to apply.

? Confidential Communications – You have the right to request that our organization communicate with you about your health and related issues in a particular manner, or at a certain location. For instance, you may ask that we contact you by mail, rather than by telephone, or at work, rather than home. If you wish to receive confidential communications, please notify the person who registers or admits you. Our organization will accommodate reasonable requests. You do not need to give a reason for your request.

? Inspection and Copies – You have the right to inspect and obtain a copy of the medical information that may be used to make decisions about you, including patient medical records and billing records. Requests to inspect and/or copy hospital records must be made in writing to the Health Information Management Department of Floyd Medical Center or Floyd Behavioral Health Center. Requests to inspect and/or copy records from Primary Care and Urgent Care offices, Family Practice offices or other Floyd affiliates should be addressed to the office(s) at which you received treatment. We may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. We may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. If you request access to psychiatric records, Georgia law allows your mental health care provider to review your record prior to granting you access for the purpose of determining whether such access would be harmful to your physical or mental health. If so, the provider may refuse to disclose the record. If this happens, you then have the right to tell us, in writing, to disclose your records to another provider of your choice.

? Amendment – You may ask us to amend your medical information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our organization. To request an amendment, call the Health Information Management Department at Floyd Medical Center at (706) 509-6180, or stop by the department on the first floor of the hospital to obtain a “Request for Amendment of Records” form.

? Accounting of Disclosures – You have a right to ask for a list of the disclosures of your health information we have made during the previous six years, but the request cannot include dates before April 14, 2003. We will not charge you for the list, unless you request more than one list per year. To request an accounting of disclosures, call the Health Information Management Department at Floyd Medical Center at (706) 509-6180, or stop by the department on the first floor of the hospital to obtain a “Request for Accounting of Disclosures” form.

? Paper Copy of This Notice – You are entitled to receive a paper copy of our Notice of Privacy Practices. You may ask us to give you a copy of this notice at any time. Copies are available at registration points at all of our hospitals and affiliate offices. You may also contact the Floyd Privacy Officer at (706) 509-3282 to request that a paper copy of this notice be mailed to you.

? Provide an Authorization for Other Uses and Disclosures – We will obtain your written authorization for uses and disclosures that are not identified by this notice or are not permitted by law.

? Complaints –- You have the right to file a complaint if you are concerned that your privacy rights may have been violated, or if you disagree with a decision we made concerning your rights as listed above. All complaints must be submitted in writing, either on paper or by e-mail, within 180 days of the incident(s) that caused the complaint, or the date that you first became aware of the incident(s). Please address complaints to: Privacy Officer, Floyd Medical Center, 420 East Second Avenue, Rome, Georgia, 30161. If you choose to submit your complaint by e-mail, please address to: Privacy@Floyd.org. You may also make a complaint to the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint.

IF YOU HAVE ANY QUESTIONS OR NEED FURTHER INFORMATION ABOUT THIS NOTICE, OR ANY OF THE RIGHTS DESCRIBED ABOVE, PLEASE CONTACT ANY OF THE FOLLOWING INDIVIDUALS:

By Phone:

• Privacy Officer, (706) 509-3282
• Director of Health Information Management, (706) 509-6180
• Guest Relations Coordinator, (706) 509-5195

In Writing to: Privacy Officer Floyd Medical Center 420 East Second Avenue

Rome, Georgia 30161

Or by e-mail at Privacy@Floyd.org