Notice of Privacy Practices

Effective Date: April 14, 2003

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 the Privacy Officer at (352) 323-5924, or by mail to the Central Florida Health Alliance Privacy Officer, Corporate Compliance and Legal Affairs, Leesburg Regional Medial Center, 600 E. Dixie Avenue, Leesburg, Florida, 34748.

WHO WILL FOLLOW THIS NOTICE

This notice describes the Central Florida Health Alliance’s (hereinafter known as “the healthcare system” or “CFHA”) practices and that of (a) any health care professional authorized to enter information into your medical record, (b) all departments and units of the system, (c) volunteers we allow to help you while you are in the facility, and (d) all members of the healthcare system’s workforce.

All the healthcare system’s entities, sites and locations follow the terms of this notice, including, but not limited to: Leesburg Regional Medical Center, The Villages Regional Hospital, LRMC Nursing Center, Ohme Rehabilitation Center, Leesburg Regional Day Surgery Center, LRMC Riverside Urgent Care Center, LRMC Home Health Services, LRMC Wellness Center, and all other affiliated sites and locations.

Contracted services also follow the terms of this notice, including any contracted physician/clinician services and all other individuals providing services at the healthcare system. These individuals, entities and facilities may share medical information with each other for payment, treatment or hospital operations purposes as described in this notice.

OUR PLEDGE REGARDING MEDICAL INFORMATION

We understand that medical information about you and your health is personal. We are committed to protecting that medical information. We create a record of the care and services you receive to provide you with quality care and to comply with certain legal requirements.

This notice applies to all of the records of your care generated by the healthcare system, whether made by organization personnel or your personal physician. Your personal physician may have different policies or notices regarding his/her use and disclosure of medical information created in his/her office or clinic. This notice tells you about the ways in which we may use and disclose information about you. It also describes your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to make sure that health-related 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 are currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

The following categories describe the ways that we use and disclose health-related 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 the categories.

For Treatment. We may use and disclose information about you to provide you with medical treatment or services. We may disclose medical information about you to physicians, nurses, technicians, medical students, or other hospital personnel who are involved in your care. (For example, a physician treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the physician may need to tell the dietician if you have diabetes so that we can arrange for appropriate meals.) Departments of the hospital also may share medical information about you in order to coordinate the things you need, such as prescriptions, lab work and x-rays. 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, clergy or others who provide services that are part of your care.

For Payment. We may use and disclose medical information about you so the treatment and services you receive at the hospital 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 surgery you received so your health plan will pay us or reimburse you for the surgery.) 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 information about you for normal hospital operations. These uses and disclosures are necessary to run the facility and make sure that all of our patients receive quality care. (For example, in the course of quality assurance activities, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you.) Some of these reviews may be conducted by independent physicians who are members of the medical staff but not employees. We may disclose medical information to “business associates” who provide contracted services such as accounting, legal representation, claims processing, accreditation, and consulting. If we do disclose medical information to a business associate, we will do so subject to a contract that provides that the information will be kept confidential. We may also combine medical information about many hospital patients to decide what additional services the hospital should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to physicians, nurses, technicians, medical students, and other personnel for review and learning purposes. We may also combine the medical information we have with medical information from other facilities to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.

Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment.

Follow-up Phone Calls. As part of your treatment plan, there may be times that you will be contacted by the healthcare system’s staff via telephone after you have service. Examples include (1) follow-up phone call after discharge from the hospital to answer any questions from the patient or family or to determine that the patient is recovering appropriately, (2) phone call to address patient satisfaction issues, or (3) phone call to provide additional education or guidance to the patient on a particular topic related to their hospital stay. Such phone calls will be limited and are meant to ensure optimum recovery, patient satisfaction and education.

Treatment Alternatives and Health-Related Benefits and Services. We may use and disclose medical information to recommend or tell you about treatment alternatives and health-related benefits or services that may be of interest to you. The healthcare system promotes community awareness of services provided by the organization. Materials sent only reflect the services available and the level of licensure and accreditation. Any unsolicited materials you receive from the healthcare system will have information on how the recipient can opt out of future mailings. To exercise your option NOT to receive unsolicited information from the healthcare system, please notify us in writing by sending your request to the Director, the Central Florida Health Alliance Charitable Foundation, 609 West Dixie Avenue, Leesburg, Florida, 34748. We will do our best to purge your name from any lists we may use.

Fundraising Activities. We may use medical information about you to contact you in an effort to raise money for the healthcare system and its operations. We only would release contact information, such as your name, address and phone number and the dates you received treatment or services at the hospital. If you do not want the hospital to contact you for fundraising efforts, you must notify the Director, the Central Florida Health Alliance Charitable Foundation, 609 West Dixie Avenue, Leesburg, Florida, 34748). This notification must be in writing.

Hospital Directory. We may include certain limited information about you in a hospital directory listing while you are an inpatient or observation patient in one of our hospitals. This information may include your name, location in the hospital, your general condition (fair, stable, 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 do not 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.

Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. 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.

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 are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients’ need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process; however, we may disclose medical information about you to people preparing to conduct a research project to help them look for patients with specific medical needs, so long as the medical information they review does not leave the healthcare system. When our staff conducts a research project, in which they look back at old medical records, your personal information will not be disclosed outside the hospital nor will you be identified in any reports. If a research project is conducted where your information cannot be held confidential, a separate process is in place for you to consent for this type of research.

Service Excellence. We may follow up your visit with us by sending to the address listed in your records a brief written survey about your satisfaction with the level of service provided to you. In some cases, the survey may be conducted by telephone or e-mail using the contact information listed in your medical record. In some instances your name may be passed on to members of the service excellence team to investigate a complaint or corroborate an incident.

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

To Avert a 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.

SPECIAL SITUATIONS

Organ and 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.

Military and Veterans. If you are a member of the armed forces, we may release medical information about you as required by military authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.

Workers’ Compensation. We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following: (a) to prevent or control disease, injury or disability; (b) to report births and deaths; (c) to report child abuse or neglect; (d) to report reactions to medications or problems with products; (e) to notify people of recalls of products they may be using; (f) 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; and (g) to notify the appropriate government authority if we believe you have been the victim of abuse, neglect or domestic violence.

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, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with applicable 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 official (a) in response to a court order, subpoena, warrant, summons or similar process; (b) to identify or locate a suspect, fugitive, material witness, or missing person; (c) about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; (d) about a death we believe may be the result of criminal conduct; (e) about criminal conduct at the hospital; and (f) 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 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.

National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President of the United States and Others. We may disclose medical information about you to authorized Federal officials so they may conduct special investigations and provide protection to the President or other officials and dignitaries.

Inmates. 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 for the institution to provide you with health care, to protect your and others’ health and safety, or for the safety and security of the correctional institution.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

You have the following rights regarding the medical information 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 that may be used to make decisions about you, you must submit your request in writing to Health Information Services, Leesburg Regional Medical Center, 600 East Dixie Avenue, Leesburg, FL 34748, or Health Information Services, The Villages Regional Hospital, 1451 El Camino Real, The Villages, FL 32159. 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. If you have questions about this prior to asking for this information in writing, please call either the LRMC Health Information Services Dept. at (352) 323-5240, or the TVRH Health Information Services Dept. at (352) 751-8846. We may deny your request to inspect and copy your medical information in certain 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 the right to request an amendment for as long as the information is kept by or for the healthcare system.

To request an amendment while you are a patient in the facility, you may ask the person who made the chart entry (such as physician or nurse). This person will include your request as a progress note in the chart to show the clarification, correction or response. Requests to amend a medical record must be made in writing and submitted to the Health Information Services Department, Leesburg Regional Medical Center, 600 East Dixie Avenue, Leesburg, FL 34748, or to the Health Information Services Department, The Villages Regional Hospital, 1451 El Camino Real, The Villages, FL 32159. If you do so in person, there is a form that will be provided to you to request this amendment. In addition, you must provide a reason that supports your request.

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 (a) was not created by us, unless the person or entity that created the information is no longer available to make the amendment; (b) is not a part of the medical information kept by or for the hospital; (c) is not part of the information which you would be permitted to inspect and copy; or (d) is accurate and complete.

Right to an Accounting of Disclosures. You have the right to request an accounting (list) of certain types of disclosures we have made of medical information about you. We are not required to account for disclosures that were: (a) authorized by you; (b) to carry out treatment, payment and healthcare operations (c) to you of health information about you; (d) for our facility directory; (e) for purposes of notifying persons involved in your care of your location, general condition or death; (f) for national security or intelligence purposes; or (g) to correctional institutions or law enforcement officials as noted above. To request an accounting of disclosures, you must submit your request in writing to the LRMC Health Information Services Department, Leesburg Regional Medical Center, 600 East Dixie Avenue, Leesburg, FL 34748, or to the TVRH Health Information Services Department, The Villages Regional Hospital, 1451 El Camino Real, The Villages, FL 32159.

Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a twelve 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 chose to withdraw or modify your request at that time before any costs are incurred. If you have questions about this prior to asking for this information in writing, please call the LRMC Health Information Services Department at (352) 323-5240, or the TVRH Health Information Services Department at (352) 751-8846.

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 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 you had, or you could ask that information about you not be included in the facility directory.)

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.

If you want to request a restriction, you must complete a “Request to Invoke/Revoke Restrictions on Disclosure of Protected Health Information” form available at any Admission or Registration area or submit your request in writing to Leesburg Regional Medical Center, Health Information Services Department, 600 East Dixie Avenue, Leesburg, Florida, 3474, or The Villages Regional Hospital, Health Information Services Department, 1451 El Camino Real, The Villages, FL 32159. The written request must include (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 or other family members). We will reply to you within 60 days.

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.) To request confidential communications, you must make your request in writing to the Health Information Services Department, Leesburg Regional Medical Center, 600 East Dixie Avenue, Leesburg, FL 34748, or the Health Information Services Department, The Villages Regional Hospital, 1451 El Camino Real, The Villages, FL 32159. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

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, www.cfhalliance.org. To obtain a paper copy of this notice, go to any Leesburg Regional Medical Center or The Villages Regional Hospital Information Desk, Admitting/Registration Area or Health Information Services.

CHANGES TO THIS NOTICE

We reserve the right to change this notice at any time. 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 the hospital. The notice will contain on the first page the effective date.. Revised copies of this notice will be available at your next visit.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the facility or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with the facility, contact the Central Florida Health Alliance Privacy Officer, Corporate Compliance and Legal Affairs, Leesburg Regional Medical Center, 600 East Dixie Avenue, Leesburg, FL 34748. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION

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.

ORGANIZED HEALTH CARE ARRANGEMENT

Central Florida Health Alliance, the independent contractor members of its Medical Staff (including your physician), and other health care providers affiliated with CFHA have agreed, as permitted by law, to share your health information among themselves for purposes of your treatment, payment or health care operations. This enables us to better address your health care needs.