Fulton County Health Center

Notice of Privacy Practice 

Effective April 14, 2003

Revised September 20, 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.

Who will follow this notice:

This notice describes Fulton County Health Center’s (FCHC) practices and that of:

  • Any health care professional authorized to enter hospital information into your medical record
  • All departments and units of the hospital
  • Any member of a volunteer group allowed to help you while you are in the hospital
  • All employees, staff and other hospital personnel
  • All entities, sites and locations of Fulton County Health Center. In addition, these sites may share medical information with each other for treatment, payment or health care operations described in this Notice.

FCHC’s Pledge regarding medical information:

FCHC understands that medical information about you and your health is personal.  We are committed to protecting your medical information.  While you receive services at FCHC, a record is created.  FCHC staff uses this record to provide you with quality care and to comply with certain legal requirements.  This notice applies to all records of your care generated by FCHC and its affiliates, whether it is made by hospital personnel or your personal physician.  Other medical practices may have different policies or notices regarding the doctor’s use and disclosure of your medical information created in the doctor’s office.

This notice will tell you about the ways in which FCHC may use and disclose medical information about you.  FCHC also describes your rights and its obligations regarding the use and disclosure of medical information.  This information is made available to you through the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

FCHC is required by law to:

  • Make sure that medical information that identifies you is kept private;
  • Inform you of any breaches to your private information and attempt to alleviate any harm from it;
  • Give you this notice of our legal duties and privacy practices with respect to medical information about you;
  • Follow the terms of the notice that is currently posted; and
  • Receive written acknowledgement from you that it has given you its notice of privacy practices

 How FCHC May use and disclose medical information about you

The below bolded and underlined categories describe different ways that FCHC is permitted or required to use and disclose medical information.  For each category of uses or disclosures FCHC will explain what is meant and offer 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 these categories.  Some information, such as certain drug and alcohol treatment information, HIV information and mental health information is entitled to special restrictions related to its use and disclosure.  We will abide by all applicable state and federal laws related to the protection of such information.

TreatmentWe may use medical information about you to provide you with medical treatment or services.  We may disclose medical information about you to doctors, nurses, technologists, pharmacists, medical and other students, or other hospital personnel involved in your care.    We may also share medical information with other providers, agencies or facilities in order to provide or coordinate the different medical services you need, such as prescriptions, lab work and x-rays.  We also may disclose medical information to providers who may be involved in your medical care after you leave the hospital, such as family members, referring physicians, family physicians, and home health care nurses.

For example, a physician treating your 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 dietary service if you have diabetes so that FCHC can arrange for appropriate meals.

PaymentWe may use and disclose medical information about you so that we may be paid for the cost of your care.  FCHC may share your information with another provider so that they may be paid for services as well.  FCHC may bill and share information with other providers, insurance companies, you or another paying third party.

For example, we may need to give information to your health plan about care you received so your health insurance will pay us or reimburse you for the care.  FCHC may also tell your health insurance about a proposed treatment in order to obtain prior approval or to determine whether your health insurance will cover the treatment.

If you pay for a health care item or service out-of-pocket, and in full, your medical information for that item or service will not be disclosed to any commercial health plan without your separate written consent.

For example, if you pay for a blood test in full, and a bill is not sent to your private insurance, we will not release that result to any private insurance without your written permission.

Health Care Operations:  We may use and disclose medical information about you for our own business operations.  These uses and disclosures are necessary to provide our services and make certain that all of our patients receive quality care.  Uses and disclosures are also necessary for certain health education and teaching programs.  We may disclose your information to another hospital for their health care operations provided they have a treatment relationship with you.

For example, we may contact you at home in order to determine your level of satisfaction with our services.  We may use medical information to review the quality of our treatment and services and to evaluate the performance of our staff in caring for you.  We may also disclose information to doctors, nurses, technicians, medical and other students, and other personnel for performance improvement and educational purposes.  We may also use medical information for business planning, management and administration of our operations.  We may also collect information on certain diseases in the form of a registry and may contact you to determine the effectiveness of your treatment and your quality of life.

Business Associates:  We may disclose medical information about you to outside persons or business who perform functions or activities on our behalf, or who provide certain professional services to us.  Under contracts with such persons or businesses, your medical information is required to be kept confidential.

For example, we may disclose information to health information exchanges (HIE), collection agencies and professionals such as lawyers, accountants and consultants.

Appointment Reminders:  We may use and disclose medical information to contact you as a reminder of your appointment for treatment or medical care.

Health-related Benefits and Services:  We may disclose medical information to tell you about health-related benefits or treatment alternatives that may be of interest to you.

Fundraising Activities:  We may use medical information about you to contact you in an effort to raise money for the Fulton County Health Center and its operations.  We will use basic demographic information (your name, address, telephone number, and dates you received services or treatment).  If you do not want FCHC to contact you for fundraising efforts, you must notify FCHC administration in writing.

Hospital Directory:  If you are hospitalized, we may include certain limited information about you in our hospital directory while you are a patient in the hospital.  This information may include your name, location in the hospital, your general condition (fair, good, serious, etc.) and 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 members of the clergy even if they don’t ask for you by name, unless that you request that we do not release it.  This is so your family, friends and clergy can visit you in the hospital and generally know how you are doing.  You may restrict or prohibit the use or disclosure of this directory information by notifying the registration clerk at the time of your admission or the Patient Access Department.

Individuals Involved In Your Care or Payment for Your Care:  We may disclose medical information about you to a family member or other designated person who is involved in your medical care.  We may also give information to someone who helps pay for your care.

For example, we may need to tell the person who comes to pick you up after a surgery, admission, or appointment that he or she may need to help you once you get home, or to act on your behalf to pick up prescriptions or medical supplies.

We may also need to use or share information about you in order to inform your family or person responsible for your care where you are and your condition in the event of an emergency or disaster.

For example, if you are admitted in an emergency and your family does not know where you are, we may contact them to tell them.

Workers’ Compensation:  We may use or disclose medical information about you for Workers’ Compensation or similar programs as authorized or required by law.  These programs provide benefits for work-related injuries or illnesses.

 As Required by Law:  We will disclose medical information about you when required to do so by federal, state or local law.  We may release medical information about you to authorized federal officials for national security, intelligence, military, or veterans activities as required by law.

Public Health Activities:  We may disclose medical information about you for public health activities and purposes.  These purposes generally include the following:

  • Preventing or controlling disease, injury or disability;
  • Reporting vital events such as births and deaths;
  • Reporting abuse or neglect;
  • Reporting adverse events or surveillance related to food, medications or defects or problems with products;
  • Notifying persons of recalls, repairs or replacements of products they may be using;
  • Notifying a person who may have been exposed to a disease or may be at risk of contracting or spreading a disease or condition

Victim of Abuse, Neglect, or Domestic Violence:  We may disclose certain medical information to government agencies authorized by law to receive reports of abuse, neglect or domestic violence if FCHC, or its agents, believe that you have been a victim.

Health Oversight Activities:  We will disclose medical information to a health oversight agency for activities authorized by law.  These oversight activities include, for example, audits, investigations, inspections and licensure by regulatory agencies.

Law EnforcementWe may release medical information if asked by a law enforcement official for the following reasons:

  • In response to a court order, subpoena, warrant, summons, or similar process;
  • Limited information to identify or locate a suspect, fugitive, material witness, or missing person, such as names and addresses in certain circumstances;
  • About the victim of a crime if, under certain limited circumstances, staff is unable to obtain a person’s agreement;
  • About a death we believe may be the result of criminal conduct;
  • About criminal conduct at FCHC; and
  • In emergency circumstances to report a crime; the location of the crime victims; or the identity, description or location of the person who committed a 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.  FCHC may 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 medical information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of cadaveric organs, eyes, or tissue for the purpose of facilitating donation and transplantation.

Research:  We may contact you about research projects that you may qualify for.  FCHC will only use and disclose your information for a research project if FCHC obtains your separate written permission.

To Avert a Serious Threat to Health or Safety:  We may use or disclose medical information about you when necessary to prevent or lessen a serious and imminent threat to your health and safety or the health and safety of the public or another person.  Disclosure would only be to persons who could help prevent or reduce the threat.

Inmates:  If you are an inmate of a correctional institution or under 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) the safety and security of the correctional institution.

Lawsuits and Disputes:  If you are involved in a lawsuit or dispute, we may release medical information about you in response to a court or administrative order.  The hospital 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.


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

Right to Inspect and CopyYou have the right to access and obtain a copy of medical information that may be used to make decisions about you or your health care.  This right does not apply to certain information, such as psychotherapy notes, information compiled for use in or created in anticipation of a civil, criminal, or administrative action or proceeding, or certain laboratory test results subject to the Clinical Laboratories Improvement Act of 1988.

To access your medical information while you are an inpatient, request assistance from your physician or nurse.  To access your medical information after you are discharged from FCHC, a completed General Authorization for Release of Information must be submitted to the FCHC’s Health Information Department.  A General Authorization for Release of Information is available through the hospital’s Health Information Department.  A fee may apply for the costs of copying, mailing or other costs associated with processing your request.

 In limited situations as described by HIPAA, FCHC may deny your request.  If your request is denied, we will tell you in writing the reason for the denial and explain whether you can have that denial reviewed.

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 the right to request an amendment for as long as we obtain the information.

To request an amendment of your medical information, a completed Request for Amendment to Protected Health Information Form must be submitted to the Privacy Officer.  A Request for Amendment to Protected Health Information Form can be obtained by calling the hospital’s Privacy Officer at 419-335-2015 or through the hospital’s Health Information Department.  Your request must include a reason for the request.

FCHC may deny your request for an amendment if it is not in writing or does not include a reason to support the request.  FCHC may also deny your request if you ask us to amend information that:

  • Was not created by us;
  • Is not part of the medical information kept by or for us;
  • Is not part of the information which you are permitted to inspect or copy; or
  • Is believed by FCHC, or its agents, to be accurate and complete

If FCHC denies your request for amendment, you may submit a written statement of disagreement, and we may prepare a written rebuttal to your statement of disagreement.  Both the statement of disagreement and rebuttal will be added to the medical information so that your request is documented.

Right to an Accounting of Disclosures.  You have the right to request a list of the disclosures we made of your medical information.  This may not include disclosures made for treatment, payment, health care operations, disclosures you specifically authorized, certain disclosures to law enforcement officials or disclosures made prior to April 14, 2003.

To request an accounting of disclosures, a completed Request for Accounting Form must be submitted to the Health Information Department.  You may obtain a Request for Accounting Form through the Privacy Officer or Health Information Department.  Your request must state a time period, which shall not be longer than the six (6) previous years and should indicate the medium you would like the list (paper or electronic) delivered.

There will be no charge for the first list you request within a twelve (12) month period.  FCHC may charge you for the costs of providing any additional lists and will notify you of the costs involved.  You may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions.  You have the right to request a restriction or limitation on the medical information FCHC uses or discloses about you for treatment, payment, or health care operations.  You also have the right to request a limit on the medical information FCHC discloses about you to someone who is involved in your care or the payment of your care, such as a family member or friend.  You may also request a restriction on your medical information being transmitted to a health information exchange (HIE).  All requests for restrictions must be made in writing and forwarded to the hospital’s Privacy Officer.

FCHC is not required to agree to your request for restrictions.  If FCHC complies with your request, your request will be followed unless the information is needed to provide you emergency treatment.  Previously released information cannot be recalled.

Right to Request Confidential Communications.  You have the right to request that FCHC communicates to you about medical matters in a certain way or at a certain location.  For example, you can ask that we contact you at work or by mail.

To request confidential communications, you must make your request in writing to the Health Information Department.  FCHC will not ask you the reason for your request, but you must specify how or where you wish to be contacted.  Staff 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 FCHC 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 the hospital’s website, www.fultoncountyhealthcenter.org.

Paper copies of this notice are available in Central Registration, the Emergency Department, Fulton Manor, and other patient care areas of Fulton County Health Center.


FCHC reserves the right to change this notice and 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 of a copy of the current notice with will contain the effective date and the most recent revision date.  Any changes to the notice will also be reflected on the copy at www.fultoncountyhealthcenter.org.


If you believe your privacy rights have been violated, or you disagree with a decision we made about your health information, you may file a written complaint to the Office of Civil Rights, Region V – Regional Manager, U.S. Department of Health and Human Services, 233 N. Michigan Avenue, Suite 240, Chicago, IL 60601.  We will take no action against you if you file a complaint about our privacy practices.

If you have any questions about this notice or any questions about our privacy practices, please call the Privacy Officer at (419) 335-2015.