Lawrence Memorial Hospital and Lawrence Hall Nursing Center
Notice of Privacy Practices
Effective; April 14, 2003
Revised: March 26, 2013;
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 the Privacy Officer of the hospital
(see the bottom of this Notice for contact details of the Privacy Officer).
This notice will tell you how we may use and disclose protected health information about you.
Protected health information means any health information about you that identifies you or for
which there is a reasonable basis to believe the information can be used to identify you. In this
notice, we refer to the protected health information as “medical information.”
This notice will also tell you about your rights and our duties with respect to medical
information about you. In addition, it will describe how you can file a complaint if you believe
we have violated your privacy rights.
WHO WILL FOLLOW THIS NOTICE
This Notice of Privacy Practices describes the practices of Lawrence Health Services and that
ÿ Any health care professional authorized to enter information into your hospital chart.
ÿ All departments and units of the hospital.
ÿ Any member of a volunteer group we allow to help you while you are in the hospital.
ÿ All employees, staff and other hospital personnel.
We all will follow the terms of this notice. In addition, we may share medical information with
each other for treatment, payment or hospital operations purposes described in this notice.
OUR PLEDGE REGARDING MEDICAL INFORMATION:
We understand that medical information about you and your health is personal and we are
committed to protecting it. Your medical information consists of records of the care and
services you receive at the hospital. We need this record to provide you with quality care
and to comply with certain legal requirements. This notice applies to all medical information,
whether created by hospital personnel or your personal doctor. Your personal doctor may
have different policies or notices regarding the doctor’s use and disclosure of your medical
information created in the doctor’s office or clinic.
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 AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.
We will share your medical information as necessary to carry out treatment, payment, or
our health care operations. 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 try to 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
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, medical students, or other hospital personnel who are involved in taking care of
you at the hospital. 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. Different departments of
the hospital also may share medical information about you in order to coordinate the different
things you need, such as prescriptions, lab work, and x-rays. We may consult or refer you
to other health care providers and share your medical information with them. We also may
disclose medical information about you to people outside the hospital who may be involved in
your medical care after you leave the hospital, such as family members, or others we use to
provide services that are part of your care.
For Payment. We may use and disclose medical information about you so that the treatment
services you receive at the hospital may be billed to and payment may be collected from you,
an insurance company, or a third party. We also may need to provide your insurance company
or a government program, such as Medicare or Medicaid, with information about your medical
condition and the health care you need to receive.
For Health Care Operations. We may use and disclose medical information about you for
hospital operations. These uses and disclosures are necessary to run the hospital and make
sure that all of our patients receive quality care. For example, we may use medical information
to review our treatment and services and to evaluate the performance of our employees in
DISCLOSURES TO WHICH YOU HAVE THE OPPORTUNITY TO OBJECT OR AGREE
We will include your name, location in the hospital; condition described in general terms (e.g.,
fair, stable, etc.) on our facility census sheet while you are a patient at the hospital. This
information may be released to people who ask for you by name. Your religious affiliation
may be given to members of the clergy, 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. If you do not want this information released you must notify the Privacy Officer or
Administration of the hospital of your objection.
Individuals Involved in Your Care or Payment for Your Care. We may disclose medical
information about you to family members, other relatives, a close personal friend, or any other
person identified by you who is involved in your medical care or payment related to your care.
We may also give information to someone who helps pay for your care. If there is a family
member, other relative, or close personal friend that you do not want to disclose medical
information about you, please notify the Privacy Officer/Medical Records Department of the
hospital, or tell our staff member who is providing care to you.
— USES AND DISCLOSURES THAT MAY BE MADE WITHOUT YOUR AUTHORIZATION OR
OPPORTUNITY TO OBJECT
Disaster Relief. We may use or disclose medical information about you to an entity assisting in
a disaster relief effort so that your family member, other relative, or close personal friend can
be notified about your condition, status, and location.
As Required by Law. We may use or disclose medical information about you when we are
required to do so by federal, state, or local law.
Public Health Activities. We may disclose medical information about you for public health
activities and purposes. 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.
Reporting Victims of Abuse, Neglect or Domestic Violence. We may disclose medical
information about you to notify an appropriate government authority if we believe you are a
victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or
when required or authorized by law.
Health Oversight Activities. We may disclose medical information to a health oversight agency
for activities authorized by law. These oversight activities include, for example, audits,
investigations, inspections, licensure or disciplinary actions. 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 medical
information about you in response to a court or administrative order. We may also disclose
medical information about you 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.
Law Enforcement. We may release medical information if asked to do so by a law enforcement
• 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 an actual or suspected victim of a crime and that person agrees to the disclosure. If
we are unable to obtain that person’s agreement, in limited circumstances, the information
may still be disclosed.
• About a death we believe may be the result of criminal conduct;
Lawrence Memorial Hospital and Lawrence Hall Nursing Center
• About criminal conduct at the hospital; and
• 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 release medical 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 medical information about
patients of the hospital to funeral directors as necessary to carry out their duties.
Organ, Eye or Tissue Donation. If you are an organ donor, we may release medical 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.
To Avert Serious Threat to Health or Safety. We may use and disclose medical 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.
Military. If you are a member of the armed forces, we may release medical information about
you as required by military command authorities. We may also release medical information
about foreign military personnel to the appropriate foreign military authority.
National Security and Intelligence. We may release medical information about you to
authorized federal officials for the conduct of intelligence, counter-intelligence, and other
national security activities authorized by law.
Protective Services for the President and Others. We may disclose medical information about
you to authorized federal officials to provide protection to the President of the United States,
certain other federal officials, or foreign heads of state.
Inmates, Persons in Custody. If you are an inmate of a correctional institution or under the
custody of a law enforcement official, we may release medical information about you to the
correctional institution or law enforcement official. This release would be necessary (1) for the
institution to provide you with health care; (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.
Workers Compensation. We may release medical information about you for workers’
compensation or similar programs. These programs provide benefits for work-related injuries or
OTHER — USES AND DISCLOSURES BASED UPON YOUR AUTHORIZATION.
Disclosures will be made only with your written authorization such as marketing, sale of PHI,
psychotherapy notes, and other uses and disclosures not described in the Notice of Privacy
Practices. You may revoke such an authorization at any time by notifying the Privacy Officer of
the hospital (see last page for contact details of the Privacy Officer), in writing of your desire to
revoke it. However, if you revoke such an authorization, it will not have any affect on actions
taken by us in reliance on it.
HOW WE WILL CONTACT YOU. Unless you tell us otherwise in writing, we may contact
you by either telephone or by mail at either your home or your office. At either location, we
may leave messages for you on the answering machine or voice mail. If you want to request
that we communicate to you in a certain way or at a certain location, see “Right to Request
Confidential Communications” section of this Notice.
Health Related Benefits and Services We may use and disclose medical information about
you to tell you about health-related benefits and services that may be of interest to you. You
have the right to request not to receive such notifications by calling the hospital Administration
or Privacy Officer (see last page for contact details of the Privacy Officer and Administration).
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
You have the following rights regarding medical information that we maintain about you.
Right to Inspect and Copy. You have the right to inspect and copy medical 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 medical information,
you must submit your request in writing to the Privacy Officer of the hospital). If you request
a copy of the information, there will be a reasonable fee for the costs of copying and other
supplies associated with your request.
We will act on your request within thirty (30) business days after we receive your request.
If we grant your request, in whole or in part, we will inform you of our acceptance of your
request and provide access and copying. Upon completion of transfer to an electronic health
record system at Lawrence Memorial Hospital, an individual can request to receive PHI in an
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 the denial be reviewed. Another
licensed health care professional chosen by the hospital 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 feel that medical information we have about you is incorrect or
incomplete, you may ask us to amend the information. You have this right for so long as we
maintain the medical information. To request an amendment, your request must be made
in writing and submitted to the Privacy Officer of the hospital. Your request must state the
amendment desired and provide a reason in support of that amendment.
We will act on your request within thirty (30) business days after we receive your request. If
we grant the request, we will make the appropriate amendment to the medical information
by appending or otherwise providing a link to the amendment. We will also inform the entities
authorized by you to receive a copy of the amendment.
We may deny your request for an amendment if it is not in writing or does not include a reason
to support the request. If we deny your request for this or other reasons, we will inform you of
the basis for the denial. You will have the right to submit a statement of disagreement with our
denial. We may prepare a rebuttal to that statement. All of this will then be included with any
subsequent disclosure of the information, or, at our election, we may include a summary of any
of that information.
If you do not submit a statement of disagreement, you may ask that we include your request
for amendment and our denial with any future disclosures of the information. We will include
your request for amendment and our denial (or a summary of that information) with any
subsequent disclosure of the medical information involved. You also will have the right to
complain about our denial of your request.
Right to an Accounting of Disclosures. You have the right to request an “accounting of
disclosures”, that is, the disclosures we made of medical information about you. The
accounting may be for up to six (6) years prior to the date on which you request the
accounting but not before April 14, 2003. Under certain circumstances your right to an
accounting of disclosures may be suspended for disclosures to a health oversight agency or law
To request an accounting of disclosures, you must submit your request in writing to the
Privacy Officer of the hospital. Usually, we will act on your request within thirty (60) business
days after we receive your request. Within that time, we will either provide the accounting of
disclosures to you or give you a written statement of when we will provide the accounting and
why the delay is necessary.
The first list you request within a twelve (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 the time before any costs are incurred.
Right to Request Restrictions. You have the right to request 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 that we restrict the uses or disclosures we make
to: (a) a family member, other relative, a close personal friend or any other person identified
by you; or, (b) for to public or private entities for disaster relief efforts. For example, you could
ask that we not use or disclose information about a surgery you had to your brother or sister.
You have the right to restrict disclosures of PHI to health plans, if the requested service has
been paid in full prior to the procedure being performed.
To request restrictions, you must make your request in writing to the Privacy Officer of the
hospital. 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.
We are not required to agree to any requested restriction. However, if we do agree, we will follow
that restriction unless the information is needed to provide emergency treatment. Even if we
agree to a restriction, either you or we can later terminate the restriction.
Right to Opt Out of Fundraising Communication. You have the right to opt out of
fundraising communications either by contacting Administration at 870-886-1265 or email
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. If you
want to request confidential communication, you must do so in writing to the Privacy Officer
of the hospital. Your request must state how or where you wish to be contacted. We will
accommodate all reasonable requests.
Right to Notification in the Event of a Breach. You will be contacted in writing in the event a
breach of your PHI occurs.
Right to a Paper Copy of This Notice. You have the right to a paper copy of our Notice of
Privacy Practices. To obtain a paper copy of this notice, contact Darlene Glass, RHIT, Health
Information Management Director, (870) 886-1243, (870) 886-5534 (fax), 1309 West Main, PO
Box 839, Walnut Ridge, AR 72476.
You may also obtain a copy of this notice at our website, www.lawrencehealth.net.
Our Right to Change Notice of Privacy Practices. 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.
Complaints. You may complain to us and to the Secretary of Health and Human Services if
you believe your privacy rights have been violated by us. You may submit a complaint to us,
in writing, to Darlene Glass, RHIT, Health Information Management Director, (870) 886-1243,
(870) 886-5534 (fax), 1309 West Main, PO Box 839, Walnut Ridge, AR 72476.
To file a complaint with the Secretary of Health and Human Services, send your complaint to
him or her in care of: Office for Civil Rights, U.S. Department of Health and Human Services,
200 Independence Avenue SW, Washington, D.C. 20201.
You will not be penalized for filing a complaint.
Questions and Information. If you have any questions or want more information concerning
this Notice of Privacy Practices, please contact the Privacy Officer of the hospital.
Contact details of the Privacy Officer
Darlene Glass, RHIT, Health Information Management Director, (870) 886-1243, (870) 886-
5534 (fax), 1309 West Main, PO Box 839, Walnut Ridge, AR 72476.
Contact details of the Health Information Management Department
Health Information Management, (870) 886-1243, (870) 886-5534 (fax), 1309 West Main, PO
Box 839, Walnut Ridge, AR 72476.
Lawrence Memorial Hospital and Lawrence Hall Nursing Center