Effective Date:  April 14, 2003
Revised:  July 2010

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO YOUR HEALTH INFORMATION. 
PLEASE REVIEW IT CAREFULLY.

When this Notice refers to "the System", it is referring to Washington Regional Medical System (Washington Regional) and certain of its affiliated entities, including: Washington Regional Medical Center, Washington Regional Home Health, Washington Regional Hospice, Fayetteville City Hospital, Washington Regional Family Clinic Fayetteville, HerHealth by Washington Regional, JPA Clinic, Washington Regional Diagnostic Clinic, Washington Regional Family Clinic Eureka Springs, Washington Regional Family Clinic Springdale, Northwest Arkansas Neuroscience Institute, WR Ozark Urology, Washington Regional Clinic for Senior Health, Washington Regional Memory Clinic, Walker Heart Institute Cardiovascular Clinic, Walker Heart Institute Harrison Cardiology, and Washington Regional Wound Care Clinic together with all Washington Regional employees, staff, volunteers, medical, nursing and other health care students, persons or entities performing services for Washington Regional under agreements containing privacy protections or to which disclosure of health information is permitted by law.  For certain activities, Washington Regional Medical Center and the independent members of its Medical and Allied Health Staffs participate in an organized health care arrangement, as recognized by law, so that they may share your health information in the course of providing your treatment, performing peer review, quality improvement activities, medical education, and conducting the payment and health care operations associated with your care at any Washington Regional Medical System facility.

WASHINGTON REGIONAL HEALTH SYSTEM'S PLEDGE AND PRIVACY OBLIGATIONS
Washington Regional is committed to protecting the confidentiality of your health information.  The System creates a record of the care and services you receive at our facilities.  We need this record to provide you with quality care and to comply with certain legal requirements.  This notice will inform you as to the ways we may use and disclose information about you and your health ("health information").  This notice also describes your rights and certain obligations we have regarding the use and disclosure of your health information.

This notice applies to all of the records of your care generated or maintained by the System, whether made by Washington Regional personnel or your doctor.

The Health Insurance Portability and Accountability Act ("HIPAA") requires that Washington Regional maintain the privacy of your health information and provide you this notice as to our legal duties and privacy practices with respect to health information.  When Washington Regional uses or discloses health information, it is required to abide by the terms of this notice.  Washington Regional reserves the right to change our privacy practices and 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.  Our current notice may be accessed on the Washington Regional web page at http://www.wregional.com.  Revised notices will also be posted in facility patient waiting areas.  You may also receive current copies of our notice by sending a written request to the System privacy officer. 

The System has a policy in place that includes a procedure for response to any breach in Protected Health Information which includes a notice to any patient for which a breach occurred.

If you have any questions about this notice, contact the Washington Regional Privacy Officer at 479-463-7640, or by writing to Washington Regional Privacy Officer, 3215 N. North Hills Blvd., Fayetteville, AR 72703.

USES AND DISCLOSURES OF YOUR HEALTH INFORMATION
The following sections describe the circumstances for which Washington Regional may use and disclose your health information without obtaining prior authorization and without offering you an opportunity to object.

• Treatment.  Washington Regional may use and disclose your health information to provide you with medical treatment and services.  Washington Regional may disclose health information about you to doctors, nurses, technicians, students, or other health care personnel who are involved in your care.  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 hospital's dietitian if you have diabetes so that we can arrange for appropriate meals. Washington Regional may also share your health information with other Washington Regional personnel or non-Washington Regional providers, agencies, or facilities in order to coordinate the services you may need, such as prescriptions, lab work and x-rays.  Washington Regional may also disclose health information to persons outside Washington Regional who may be involved in your continuing medical care after you leave Washington Regional, such as another hospital, a nursing home, a home health provider, a rehabilitation hospital, community agencies and family members.
• Payment.  Your health information will be used, as necessary, to secure payment for your health care services.  Washington Regional may use your health information so that the treatment and services you receive at Washington Regional or from other entities, such as an ambulance company, may be billed and payment collected from you, an insurance company or a third party.  For example, we may share your health information with your health insurance company and provide your diagnosis and treatment in order to assist the insurer in processing the claim for the healthcare services provided to you.
• Health Care Operations.  Washington Regional may use and/or disclose your information for the purposes of our day-to-day operations and functions.  We may also disclose your information to another covered entity to allow it to perform its day-to-day functions, but only to the extent that we both have a relationship with you.  For example, we may compile your health information, along with that of other patients, in order to allow a team of our health care professionals to review that information and make suggestions concerning how to improve the quality of care provided at this facility.  Also, we may contact you as part of our efforts to raise funds for the Organization.  All fundraising communications will include information about how you may opt out of future fundraising communications.
• Washington Regional may also use and/or disclose your health information:  
  • To create material(s) that originally had any identifying information concerning you deleted from the final material(s);
  • When required by law;
  • For public health purposes such as vital statistics and preventing or controlling disease;
  • To disclose information about victims of abuse, neglect or domestic violence;
  • For health oversight activities, such as audits or civil, administrative or criminal investigations;
  • For judicial or administrative proceedings;
  • For law enforcement purposes;
  • To assist coroners, medical examiners or funeral directors with their official duties;
  • To facilitate organ, eye or tissue donation;
  • For certain research projects that have been evaluated and approved through a research approval process that takes into account patients' need for privacy.
  • To avert a serious threat to health safety;
  • For specialized governmental functions, such as military, national security, criminal corrections, or public benefit purposes; a
  • For workers' compensation purposes, as permitted by law.
• Washington Regional may also use or disclose your health information in the following circumstances.  However, except in emergency situations, Washington Regional will inform you of our intended action prior to making any such uses and disclosures and will, at that time, offer you the opportunity to object.
  • Directories.  Washington Regional may maintain a directory of patients that includes your name and location within the facility, your religious designation, and information about your condition in general terms that will not communicate specific health information about you.  Except for your religion, Washington Regional may disclose this information to any person who asks for you by name.  Washington Regional may disclose all directory information to members of the clergy.
  • Notifications.  Washington Regional may disclose to your relatives or close personal friends any health information that is directly related to that person's involvement in the provision of, or payment for, your care.  Washington Regional may also use and disclose your health information for the purpose of locating and notifying your relatives or close personal friends of your location and general condition or death, and to Organizations that are involved in those tasks during disaster situations.
• Except as described above, disclosures of your health information will be made only with your written authorization.  You may revoke your authorization at any time, in writing, unless we have taken action in reliance upon your prior authorization, or if you signed the authorization as a condition of obtaining insurance coverage.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
Your health information is the property of Washington Regional.  You have the following rights, however, regarding health information we maintain about you:

• Right to Inspect and Copy.  With certain exceptions, you have the right to inspect and copy your health information for as long as we maintain that information.
  
  To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to the appropriate Medical Record Department of the Washington Regional entity that maintains your health information.  A list of all Washington Regional record departments and their addresses is set forth at the end of this Notice.  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.
• Right to Request an Amendment or Addendum.  If you believe that health information Washington Regional has about you is incorrect or incomplete, you may ask us to amend the information or add an addendum (addition to the record).  You have the right to request an amendment or addendum for as long as the information is kept by or for Washington Regional.  
  
  To request an amendment, your request must be made in writing and submitted to the medical record department of the Washington Regional entity that maintains your information at the appropriate address set forth at the end of this Notice. In addition, you must provide a reason that supports your request.
  
  Washington Regional 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 Washington Regional medical staff or employees, 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 Washington Regional;
  • Is not part of the information which you would be permitted to inspect and copy; or
  • Is accurate and complete.
• Right to an Accounting of Disclosures.  You have the right to request an "accounting of disclosures".  This is a list of the disclosures we made of your health information.  This right does not apply to disclosures made for purposes of treatment, payment, and health care operations or disclosures that are subject to certain restrictions, exceptions, and limitations imposed by law.  
  
  To request an accounting of disclosures, you must submit your request in writing to Washington Regional Privacy Officer, 3215 N. North Hills Blvd., Fayetteville, AR 72703.  Your request must state a time period that may not be longer than six years.  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.  Washington Regional 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.
  
  We will ordinarily respond to your request for an accounting within 60 days.  If we require additional time to prepare the accounting you have requested, we will notify you in writing about the reason for the delay and the date you can expect to receive the accounting.
• 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 performed at Washington Regional.
  
  We are not required to agree to your request.  If we do agree, our agreement must be in writing and we will comply with your request unless the information is needed to provide you emergency treatment.  To request a restriction, you must make your request in writing to the Washington Regional Privacy Officer, 3215 N. North Hills Blvd., Fayetteville, AR  72703.  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 more confidential way by requesting that we communicate with you by alternative means or at alternative locations.  For example, you can ask that we only contact you at home or by mail.
  
  To request more confidential communications, please make your request in writing to Privacy Officer, 3215 N. North Hills Blvd., Fayetteville, AR  72703.  We will not ask you the reason for your request, and we will try to accommodate reasonable requests.  Please specify in your request how or where you wish to be contacted, and how payment for your health care will be handled if we communicate with you through the requested alternative method or location.
• 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.  Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. 
  
  You may obtain a copy of this notice at our website, http://www.wregional.com or by writing Privacy Officer, 3215 N. North Hills Blvd., Fayetteville, AR 72703, telephone number 479-463-7640.

COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with Washington Regional or with the Secretary of the Department of Health and Human Services.  To file a written complaint with Washington Regional, contact Privacy Officer, 3215 N. North Hills Blvd., Fayetteville, AR 72703, telephone number 479-463-7640.

You will not be penalized for filing a complaint.

OTHER USES OF HEALTH INFORMATION.
Other uses and disclosures of health information not covered by this notice or the laws that apply to Washington Regional will be made only with your written authorization, giving us permission for such uses or disclosures.  If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time, by contacting Privacy Officer, 3215 N. North Hills Blvd., Fayetteville, AR 72703.  If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization.   Washington Regional is unable to take back any disclosures already made with your permission, and we will retain our records of the care that we provided to you as required by law.

Washington Regional Medical Record Departments:

Washington Regional Family Clinic Eureka Springs
Attn: Medical Records
146 A Passion Play Road
Eureka Springs, AR  72632
 
HerHealth
Attn: Medical Records
3215 N. North Hills Blvd, Suite B
Fayetteville, AR  72703

Fayetteville City Hospital
Attn: Medical Records
221 S. School Avenue
Fayetteville, AR 72701
 
Washington Regional - Home Health
Attn: Director
88 Colt Square
Fayetteville, AR  72703

Washington Regional Diagnostic Clinic
Attn: Medical Records
3000 Northwest A
Bentonville, AR  72712
 
Washington Regional - Hospice
Attn: Director
34 Colt Square
Fayetteville, AR  72703

Washington Regional Family Clinic Fayetteville
Attn: Medical Records
3053 N. College Ave.
Fayetteville, AR  72703
 
Washington Regional Medical Center
Attn: Medical Records
3215 N. North Hills Blvd
Fayetteville, AR  72703

Northwest Arkansas Neuroscience Institute
Attn:  Medical Records
3336 N. Futrall Drive
Fayetteville, AR  72703

Washington Regional Family Clinic Springdale
Attn:  Medical Records
813 Founders Park Drive
Springdale, AR  72762 

Washington Regional Senior Clinic
Attn:  Medical Records
12 East Appleby Road
Fayetteville, AR  72703

Ozark Urology
Attn:  Medical Records
3211 N. North Hills Boulevard
Fayetteville, AR  72703

Walker Heart Institute Cardiovascular Clinic
Attn:  Medical Records
3211 N. North Hills Boulevard
Fayetteville, AR  72703

Walker Heart Institute Harrison Cardiology Clinic
Attn:  Medical Records
702 N. Spring Street
Harrison, AR  72601