NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW ITCAREFULLY.
WE ARE REQUIRED BY LAW TO PROTECT MEDICAL INFORMATION ABOUT YOU
We are required by law to protect the privacy of medical
information about you and that identifies you. This medical
information may be information about health care we provide to you or
payment for health care provided to you. It may also be information
about your past, present, or future medical condition.
We are also required by law to provide you with this Notice of
Privacy Practices explaining our legal duties and privacy practices
with respect to medical information. We are legally required to follow
the terms of this Notice. In other words, we are only allowed to use
and disclose medical information in the manner that we have described
in this Notice. We are required to notify you of a breach of unsecured
protected health information involving your medical information.
We may change the terms of this Notice in the future. We reserve
the right to make changes and to make the new Notice effective for all
medical information that we maintain. If we make changes to the
Notice, we will:
- Post the new Notice in our waiting area.
- Have copies of the new Notice available upon request (you may
always contact our Privacy Officer at 812-355-6900 to obtain a copy of
the current Notice).
- Post the new Notice on Premier Healthcare’s website,
The rest of this Notice will:
- Discuss how we may use and disclose medical information about you.
- Explain your rights with respect to medical information about you.
- Describe how and where you may file a privacy-related complaint.
If, at any time, you have questions about information in this
Notice or about our privacy policies, procedures or practices, you can
contact our Privacy Officer at 812-355-6900.
WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU IN SEVERAL CIRCUMSTANCES.
We use and disclose medical information about patients every
day. This section of our Notice explains in some detail how we may use
and disclose medical information about you in order to provide health
care, obtain payment for that health care, and operate our business
efficiently. This section then briefly mentions several other
circumstances in which we may use or disclose medical information
We may use and disclose medical information about you to provide
health care treatment to you. In other words, we may use and disclose
medical information about you to provide, coordinate or manage your
health care and related services. This may include communicating with
other health care providers regarding your treatment and coordinating
and managing your health care with others.
We may use and disclose medical information about you to obtain
payment for health care services that you received. This means that we
may use medical information about you to arrange for payment (such as
preparing bills and managing accounts). We also may disclose medical
information about you to others (such as insurers, collection
agencies, and consumer reporting agencies). In some instances, we may
disclose medical information about you to an insurance plan before you
receive certain health care services because, for example, we may want
to know whether the insurance plan will pay for a particular
3. Healthcare Operations
We may use and disclose medical information about you in performing
a variety of business activities that we call "health care
operations." These "health care operations" activities allow us to,
for example, improve the quality of care we provide and reduce health
care costs. For example, we may use or disclose medical information
about you in performing the following activities:
- Reviewing and evaluating the skills, qualifications, and
performance of health care providers taking care of you.
- Providing training programs for students, trainees, health care
providers or non-health care professionals to help them practice or
improve their skills.
- Cooperating with outside organizations that evaluate, certify or
license health care providers, staff or facilities in a particular
field or specialty.
- Reviewing and improving the quality, efficiency and cost of care
that we provide to you and our other patients.
- Improving health care and lowering costs for groups of people who
have similar health problems and helping manage and coordinate the
care for these groups of people.
- Cooperating with outside organizations that assess the quality of
the care others and we provide, including government agencies and
- Planning for our organization's future operations.
- Resolving grievances within our organization.
- Reviewing our activities and using or disclosing medical
information in the event that control of our organization
- Working with others (such as lawyers, accountants and other
providers) who assist us to comply with this Notice and other
4. Persons Involved in Your Care
We may disclose medical information about you to a relative, close
personal friend or any other person you identify if that person is
involved in your care and the information is relevant to your care. If
the patient is a minor, we may disclose medical information about the
minor to a parent, guardian or other person responsible for the minor
except in limited circumstances.
We may also use or disclose medical information about you to a
relative, another person involved in your care or possibly a disaster
relief organization (such as the Red Cross) if we need to notify
someone about your location or condition.
You may ask us at any time not to disclose medical information
about you to persons involved in your care. We will agree to your
request and not disclose the information except in certain limited
circumstances (such as emergencies) or if the patient is a minor. If
the patient is a minor, we may or may not be able to agree to your
5. Required by Law
We will use and disclose medical information about you whenever we
are required by law to do so. There are many state and federal laws
that require us to use and disclose medical information. For example,
state law requires us to report gunshot wounds and other injuries to
the police and to report known or suspected child abuse or neglect to
the Department of Social Services. We will comply with those state
laws and with all other applicable laws.
6. National Priority Uses and Disclosures
When permitted by law, we may use or disclose medical information
about you without your permission for various activities that are
recognized as “national priorities.” In other words, the government
has determined that under certain circumstances (described below), it
is so important to disclose medical information that it is acceptable
to disclose medical information without the individual’s
permission. We will only disclose medical information about you in the
following circumstances when we are permitted to do so by law. Below
are brief descriptions of the “national priority” activities
recognized by law.
- Threat to health or safety: We may use or disclose medical
information about you if we believe it is necessary to prevent or
lessen a serious threat to health or safety.
- Public health activities: We may use or disclose medical
information about you for public health activities. Public health
activities require the use of medical information for various
activities, including, but not limited to, activities related to
investigating diseases, reporting child abuse and neglect, monitoring
drugs or devices regulated by the Food and Drug Administration, and
monitoring work-related illnesses or injuries. For example, if you
have been exposed to a communicable disease (such as a sexually
transmitted disease), we may report it to the State and take other
actions to prevent the spread of the disease.
- Abuse, neglect or domestic violence: We may disclose medical
information about you to a government authority (such as the
Department of Social Services) if you are an adult and we reasonably
believe that you may be a victim of abuse, neglect or domestic
- Health oversight activities: We may disclose medical information
about you to a health oversight agency which is basically an agency
responsible for overseeing the health care system or certain
government programs. For example, a government agency may request
information from us while they are investigating possible insurance
- Court proceedings: We may disclose medical information about you
to a court or an officer of the court (such as an attorney). For
example, we would disclose medical information about you to a court if
a judge orders us to do so.
- Law enforcement: We may disclose medical information about you to
a law enforcement official for specific law enforcement purposes. For
example, we may disclose limited medical information about you to a
police officer if the officer needs the information to help find or
identify a missing person.
- Coroners and others: We may disclose medical information about you
to a coroner, medical examiner, or funeral director or to
organizations that help with organ, eye and tissue transplants.
- Workers’compensation: We may disclose medical information about
you in order to comply with workers’ compensation laws.
- Research organizations: We may use or disclose medical information
about you to research organizations if the organization has satisfied
certain conditions about protecting the privacy of medical
- Certain government functions: We may use or disclose medical
information about you for certain government functions, including but
not limited to military and veterans’ activities and national security
and intelligence activities. We may also use or disclose medical
information about you to a correctional institution in some
Other than the uses and disclosures described above (#1-6), we will
not use or disclose medical information about you without the
authorization or signed permission of you or your personal
representative. In some instances, we may wish to use or disclose
medical information about you and we may contact you to ask you to
sign an authorization form. In other instances, you may contact us to
ask us to disclose medical information and we will ask you to sign an
If you sign a written authorization allowing us to disclose medical
information about you, you may later revoke (or cancel) your
authorization in writing (except in very limited circumstances related
to obtaining insurance coverage). If you would like to revoke your
authorization, you may write us a letter revoking your authorization
and forward it to our Privacy Officer. If you revoke your
authorization, we will follow your instructions except to the extent
that we have already relied upon your authorization and taken some
YOU HAVE RIGHTS WITH RESPECT TO MEDICAL INFORMATION ABOUT
You have several rights with respect to medical information about
you. This section of the Notice will briefly mention each of these
1. Right to a Copy of This Notice
You have a right to have a paper copy of our Notice of Privacy
Practices at any time. In addition, a copy of this Notice will always
be posted in our waiting area and on our Premier Healthcare website,
www.premierhealthcare.org. If you would like to have a copy of our
Notice, ask our receptionist for a copy.
2. Right of Access to Inspect and Copy
You have the right to inspect (which means see or review) and
receive a copy of medical information about you that we maintain in
certain groups of records. If we maintain your medical records in
electronic format, you may obtain an electronic copy of your medical
records in the electronic form or format you request, so long as the
information is readily producible in that form or format. If not
readily producible in the electronic form or format you request, we
will provide it to you in a reasonable alternative format. You may
also instruct us in writing to send an electronic copy of your medical
records to a third party. If you would like to inspect or receive a
copy of medical information about you, you must provide us with a
request in writing. You may write us a letter requesting access or
fill out an Access Request Form. Access Request Forms are available
from our office or Premier Healthcare's Privacy Officer.
We may deny your request in certain circumstances. If we deny your
request, we will explain our reason for doing so in writing. We will
also inform you in writing if you have the right to have our decision
reviewed by another person.
If you would like a copy of the medical information about you, we
will charge you a fee to cover the costs of the copy. Our fees for
electronic copies of your medical records will be limited to the
direct labor costs associated with fulfilling your request.
We may be able to provide you with a summary or explanation of the
3. Right to Have Medical Information Amended
You have the right to have us amend (which means correct or
supplement) medical information about you that we maintain in certain
groups of records. If you believe that we have information that is
either inaccurate or incomplete, we may amend the information to
indicate the problem and notify others who have copies of the
inaccurate or incomplete information. If you would like us to amend
information, you must provide us with a request in writing and explain
why you would like us to amend the information. You may either write
us a letter requesting an amendment or fill out an Amendment Request
Form. Amendment Request Forms are available from our Privacy
We may deny your request in certain circumstances. If we deny your
request, we will explain our reason for doing so in writing. You will
have the opportunity to send us a statement explaining why you
disagree with our decision to deny your amendment request and we will
share your statement whenever we disclose the information in the
4. Right to an Accounting of Disclosures We Have Made
You have the right to receive an accounting (which means a detailed
listing) of disclosures that we have made for the previous six (6)
years. If you would like to receive an accounting, you may send us a
letter requesting an accounting, fill out an Accounting Request Form,
or contact our Privacy Officer. Accounting Request Forms are available
from our office or Premier Healthcare’s Privacy Officer.
The accounting will not include several types of disclosures,
including disclosures for treatment, payment or health care
operations. The accounting will also not include disclosures made
prior to April 14, 2003.
If you request an accounting more than once every twelve (12) months, we may charge you a fee to cover the costs of preparing the accounting.
5. Right to Request Restrictions on Uses and Disclosures
You have the right to request that we limit the use and disclosure
of medical information about you for treatment, payment and health
care operations. Except as otherwise required by law, we are not
required to agree to your request unless:
- The disclosure is to a health plan for purpose of carrying out
payment of health care operations (and is not for purposes of carrying
out treatment); and,
- The medical information pertains solely to a health care item or
service for which the health care provided involved has been paid
out-of-pocket in full.
If we agree to your request, we must follow your restrictions
(except if the information is necessary for emergency treatment).You
may cancel the restrictions at any time. In addition, we may cancel a
restriction at any time as long as we notify you of the cancellation
and continue to apply the restriction to information collected before
6. Right to Request an Alternative Method of Contact
You have the right to request to be contacted at a different
location or by a different method. For example, you may prefer to have
all written information mailed to your work address rather than to
your home address.
We will agree to any reasonable request for alternative methods of
contact. If you would like to request an alternative method of
contact, you must provide us with a request in writing. You may write
us a letter or fill out an Alternative Contact Request
Form. Alternative Contact Request Forms are available from our Privacy
YOU MAY FILE A COMPLAINT ABOUT OUR PRIVACY PRACTICES.
If you believe that your privacy rights have been violated or if
you are dissatisfied with our privacy policies or procedures, you may
file a written complaint either with us or with the federal
government. We will not take any action against you or change our
treatment of you in any way if you file a complaint.
To file a written complaint with us, you may bring your complaint directly to our Privacy Officer, or you may mail it to the following address:
Premier Healthcare Privacy Officer,
550 Landmark Ave
Bloomington, IN 47403
To file a written complaint with the federal government, please use
the following contact information:
U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201
Toll-Free Phone: (800) 368-1019
TDD Toll-Free: (800) 537-7697