Notice of Privacy Practices

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.

The terms of this Notice apply to physician practices and services located in the Department of OB/Gyn at St. John's Mercy Medical Center1. These practices and services are hereinafter referred to collectively as "the Department of OB/Gyn."
This Notice is intended to inform you about our practices related to your medical records. Generally, the Department of OB/Gyn is required by law to ensure that medical information that identifies you is kept private. We are required to give you this information related to our privacy practices with respect to any medical information we create or receive about you. We are required by law to follow the terms of our most recent Notice.
This Notice will explain how the Department of OB/Gyn may use and disclose your medical information, our obligations related to the use and disclosure of your medical information, and your rights related to any medical information that we have about you.
We have listed some of the reasons why we might use or disclose your medical information with some examples. Not every use or disclosure is discussed, but all of the ways that we are allowed to use and disclose information falls into one of the categories.

Use and Disclosure of Medical Information:
For Treatment: To provide you with medical treatment or services, we may need to use or disclose information about you to personnel involved in your treatment. For example, a doctor may need to consult another provider about your medical history before providing treatment.
For Payment: We may use and disclose your medical information to bill and receive payment for the treatment that you received here. For example, we may use or disclose your medical information to your insurance company about a service you received at St. John's so that your insurance company can pay us or reimburse you for the service.
For Health Care Operations: We can use and disclose medical information about you for Hospital operations. For example, we may use or disclose medical information about you to evaluate our staff's performance in caring for you.

Uses and Disclosures of Medical Information that Do Not Require Your Authorization:
We can use or disclose health information about you without your authorization when there is an emergency, when we are required by law to treat you, or when we are required by law to use or disclose certain information.
We may use or disclose your health information without your authorization in any of the following circumstances:

• When it is required by federal, state or other law;

• When it is needed for public health activities;

• When reporting information about victims of abuse, neglect or domestic violence;

• When disclosing information for the purpose of health oversight activities;

• When disclosing information for judicial and administrative proceedings;

• When disclosing information for law enforcement purposes;

• When disclosing information about deceased persons to medical examiners, coroners and funeral directors;

• When disclosing or using information for organ and tissue donation purposes;

• When disclosing information for research purposes;

• When we believe in good faith that the disclosure is necessary to avert a serious health or safety threat;

• When disclosure is necessary for specialized government functions;

• When disclosure is necessary to comply with worker's compensation laws or purposes.

Planned Uses or Disclosures to Which You May Object:
We may use or disclose your health information for any of the purposes described in this section unless you affirmatively object to or otherwise restrict a particular release. You may direct your objections or restrictions in writing to your caregiver or to the contact office listed in this Notice.

• We may use or disclose your health information to contact you and remind that you have an appointment for treatment or medical care.

• We may use or disclose your health information to provide you with information about or recommendations of possible treatment options or alternatives that may interest you.

• We may use and disclose your health information to a group health plan, health insurance issuers, HMO or plan sponsor.

• We may release health information about you to a friend and/or family member who is involved in your care. We may tell your family and/or friends of your medical information relevant to that person's involvement in your care and that you are at the Department of OB/Gyn for treatment or services. We may also give this information to someone who will help or is helping to pay for your care.

• We can disclose health information about you to a public or private entity that is authorized by law or its charter to assist in disaster relief efforts (e.g., the American Red Cross).

Other Uses or Disclosures:
If you provide us written authorization to use or disclose information, you can change your mind and revoke your authorization at any time, as long as you cancel your authorization. If you revoke your authorization, we will no longer use or disclose the information. However, we will not be able to take back any disclosures that we have already made.
Your Rights with Respect to Health Information:

• Right to Inspect and Copy Your Health Information: You have the right to inspect and copy your health information, with certain exceptions. If you request copies of information, we may charge a fee for any costs associated with your request, including the cost of copies, mailing or other supplies.

• Right to Request Information in Certain Form and Location: You have the right to request health information in a certain form or at a specific location. For instance, you can request that we not contact you at work. The request must tell us how and/or where you want to receive information. We will accommodate reasonable requests.

• Right to Request Amendment to Your Health Information: You have a right to request that your health information be amended if you believe that it is incorrect or incomplete. You must give the reason that you want the amendment added to your health information. Your request must be in writing.

• Right to an Accounting of Disclosures: You have the right to receive an accounting of disclosures of medical information that we have made, with some exceptions. You have the right to receive one (1) free accounting every twelve (12) months. If you request more than one (1) accounting in any twelve (12) month period, we may charge you a reasonable fee for the costs of providing that list.

• Right to Request Restrictions: You have the right to request that we restrict any use or disclosure of your health information. We are not required to accept any restriction that you request. If we do agree to your restriction, we will comply with your request. For example, a patient who does not want their physician to share health information with other physicians involved in his or her care may request to restrict such disclosure.

You have the right to a paper copy of this Notice. Even if you have agreed to receive this Notice in another form, you can still have a paper copy of this Notice. To obtain a paper copy of this Notice or to submit a written request related to "Your Rights" contact the appropriate office listed below:

Group Administrator
Department of OB/Gyn
St. John's Mercy Medical Center
621 South New Ballas Road, Suite 2009B
St. Louis, MO 63141
314-251-6880

Complaints
If you have any questions about the content of this Notice, or if you need to contact someone about the information contained in this Notice, the contact person is:

Privacy Officer
The Department of OB/Gyn
St. John's Mercy Medical Center
621 South New Ballas Road, Suite 2009B
St. Louis, MO 63141
314-251-6880

You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. You will not be retaliated against for filing a complaint with either the Department of OB/Gyn or the U.S. Department of Health and Human Services.

Changes to This Notice
We reserve the right to change or modify the information contained in this Notice. Any changes that we make will comply with appropriate federal, state or other laws. At each first delivery of service, the Department of OB/Gyn will provide the most recent copy of this Notice and post this version at our affiliated facilities. Also, you can call or write our contact person to obtain the most recent version of this Notice.


1The physicians participating in my care at the Department of OB/Gyn are either independent physicians who are engaged in the private practice of medicine who have been granted privileges to use our facilities for the care of their patients, or licensed physicians who are engaged in a post graduate medical education program. I understand that all medical decisions regarding my care and treatment at the Department of OB/Gyn are made by such physicians not The Department of OB/Gyn.