Notice of Privacy Practices

Effective Date: June 1, 2018

This Notice of Privacy Practices (“Notice”) serves as a notice for all Habersham Medical Center (“HMC”) entities providing health care services (such HMC entities referred to collectively as “we” or “our”). This Notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this Notice carefully. If you have any questions about this Notice, please contact a registration representative at the hospital, physician’s clinic or other HMC entity where you are receiving health care services.


Who Will Follow This Notice

This Notice applies to our workforce members, including employees, volunteers, students and trainees. This Notice also applies to other health care and service providers that provide care or services at our facilities, or for our patients, in that, as a condition to providing services at our facilities, such providers must agree to comply with our policies, including our policies relating to patient privacy. This Notice, however, only details our privacy policies and does not govern the independent practices or operations of health care and service providers, such as the privacy practices that your doctor, if not employed by us, may use in his or her private office.


Our Pledge Regarding Medical Information

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the health care services you receive from us. We need this record to provide you with quality health care services and to comply with certain legal requirements. This Notice applies to all of the records of your care that we generate.


We are required by law to:


  • Make sure that medical information that identifies you is kept private;


  • Give you this Notice of our legal duties and privacy practices with respect to medical information about you; and


  • Follow the terms of the Notice that is currently in effect.


How We May Use & Disclose Medical Information About You

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 give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories:


For Treatment: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, health care students, clergy, or others who are involved in your health care services. For example, your medical information may be shared with a physician to whom you have been referred in order to ensure that the physician has the necessary information to diagnose or treat you. We also may use your medical information to coordinate the different things you need, such as prescriptions, lab work and x-rays. If you are in one of our facilities, we also may disclose medical information about you to people outside the facility who may be involved in your medical care after you leave our facility.


For Payment: We may use and disclose medical information about you so that the treatment and services we provided to you, or that was provided to you by another facility, provider, or physician, may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about your treatment so they can pay us or reimburse you. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.


For Health Care Operations: We may use and disclose medical information about you to improve our services or support our business activities. For example, we may use medical information to review our treatment and services, to evaluate the performance of our staff in caring for you. We may also disclose information to doctors, nurses, technicians, health care students, and other personnel for review and learning purposes. We or our designee may send you a patient satisfaction survey via mail or to an email address that you provided to us. Specific individual information will not be included in the email without authentication of a specific patient identifier to access the survey.


Health-Related Benefits & Services: We may use and disclose medical information to tell you about health related benefits, services, or health education resources, such as screenings, seminars, classes, or other programs that may be of interest and beneficial to you.


Patient Assistance Programs: We may use and disclose your information to third parties for the purpose of determining whether you qualify for a private or government patient assistance program that would reduce the amount you owe to HMC.


Fundraising Activities: We may use information about you to contact you in an effort to raise money for our operations. For this purpose, we may use your name, address and phone number, the dates you received treatment or services and the department in which you received those services. If you do not want to be contacted for fundraising efforts, you will be given the opportunity to notify the appropriate Privacy Officer in writing.


Hospital Directory: If you are receiving health care services in one of our hospitals, unless you advise the registration representative otherwise, 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 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 rabbi, even if they don't 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. 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.


Individuals Involved in Your Care or Payment for Your Care: Unless you object, we may share information about you to a care giver who may be a friend or family member. We may also give information to someone who helps pay for your care. If you are unable to object to such a disclosure, we may discuss your medical information with a family member, friend, or other person if, using professional judgment, we conclude that you do not object. Only the information that is relevant to your care or payment for your care will be disclosed.


Research: Under certain circumstances, we may use and disclose medical 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 internal approval process.


As Required By Law: We will disclose medical information about you when required to do so by federal, state or local law.


Special Situations: In the following special situations we may release your medical information: organ and tissue donation, active duty military personnel and veterans, worker’s


compensation, public health activities, health oversight activities, lawsuits and disputes, law enforcement, coroners and medical examiners, national security and intelligence activities, protective services for the President and others, inmates, and research, public health threat and safety of others, disaster relief efforts.


Other Uses of Medical Information: Most uses and disclosures of psychotherapy notes, uses and disclosures of medical information for marketing purposes and certain disclosures that constitute a sale of your medical information will require your written permission. Additionally, other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are 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.


Your Rights Regarding Your Medical Information

You have the following rights regarding medical information we obtain about you:


Right to Inspect and Copy: You have a right to inspect and obtain a copy of medical information that may be used to make decisions about your care. Usually, this includes medical, laboratory and billing records, but may not include all psychotherapy notes.


  • Request in writing to inspect and copy medical information that may be used to make decisions about you. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.


  • We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that another licensed health care professional chosen by us 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.


  • If your request is denied you may request that the denial be reviewed, and that decision will be final. You may be charged a fee for the costs associated with copying, mailing, or other supplies associated with the request. If all or any portion of your health information in an electronic format, you may request an electronic copy.


Right to Amend: If you feel that medical information we have about you is incorrect or incomplete, you have the right to request in writing that we amend the information by providing


the reason for the amendment. You have the right to request an amendment for as long as the information is kept by or for us.


We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. 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 medical information kept by or for us;
  • Is not part of the information which you would be permitted to inspect and copy; or
  • Is accurate and complete.


If we deny your request for an amendment, we will do so in writing and you have the right to file a statement of disagreement.


Right to an Accounting of Disclosure: You have the right to request in writing an "accounting of disclosures." This is a list of the disclosures we made of medical information about you to others, excepting disclosures relating to treatment, payment and health care operations. Your request must state a time period which may not be longer than six years. Your request should indicate in what form you want the list (for example, on paper, or; 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 Receive Notice of Breaches: You have the right to receive notifications of breaches of your unsecured medical information.


Right to Request Restrictions: You have the right to request in writing a restriction or limitation on the medical 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 medical 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 performed. 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. 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.


Right to Request Confidential 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. Please advise the registration representative how or where you wish to be contacted. We will not ask you the reason for your request. We will accommodate all reasonable requests.



Right to a Paper Copy of This Notice: You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time by requesting a copy from the registration representative or by contacting HMC’s Privacy Office.


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 medical 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 in our facilities and this Notice will be available on the Habersham Medical Center website. The Notice will contain on the first page, in the top left-hand corner, the effective date. In addition, each time you register at or are admitted as a patient, you have the right to request a copy of the current Notice in effect.


Questions About This Notice or Complaints: If you believe your privacy rights have been violated, you may file a written complaint with the Health System, by calling the HABERSHAM MEDICAL CENTER PRIVACY OFFICER at 706-839-4077 or writing a letter to Attn: HABERSHAM MEDICAL CENTER HIPAA PRIVACY OFFICE, P. O. BOX 37,

DEMOREST, GA 30535. While we will make every effort to resolve any complaints, please know that you also have the right to file a written complaint with the Secretary of the Department of Health and Human Services. The quality of your care will not be jeopardized nor will you be penalized for filing a complaint.