Effective Date: 04/14/03

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 PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.

If you have any questions about this notice please contact our privacy officer at (631) 726-8200.

We are required by applicable federal and state law to maintain the privacy of your medical information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your medical information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect 04/14/2003, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all medical information that we maintain, including medical information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this notice and make the new notice available upon request.

You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice.

Who Will Follow This Notice

This notice describes our hospital’s practices and those participants listed below in our organized health care arrangement. As such, we may share your medical information and the medical information of others we service with each other as needed for treatment, payment or health care operations relating to our organized health care arrangement.

This notice does not imply any joint venture or any other special association or legal relationship between the hospital and its medical staff. This notice is an administrative tool permitted by federal law allowing the hospital and medical staff to tell you about common privacy practices.

Along with the hospital, the following participate in our organized health care arrangement:

• Members of our medical staff and their employees or workforce who provide services or support to the physician at the hospital.
• Our employed physicians and their office staff.

Uses and Disclosures of Medical Information

We use and disclose medical information about you for treatment, payment, and health care operations. For example:

Treatment: We may use or disclose your medical information to a physician or other health care provider in order to provide treatment to you.

Payment: We may use and disclose your medical information to obtain payment for services we provide to you. We may disclose your medical information to another health care provider or entity subject to the federal and state Privacy Rules so they can obtain payment.

Health Care Operations: We may use and disclose your medical information in connection with our health care operations. These uses are necessary to make sure that all our patients receive quality care. Some examples are:

• Review of our treatment or services to evaluate the performance of our staff providing your care;
• Sending you a satisfaction survey;
• Review of information about many of our patients to determine if additional services should be added or perhaps are no longer needed;information may be given to our doctors, nurses, medical and health care students, and other personnel to be used for education and learning purposes;
• We may remove information that identifies you from the medical information so others may use it for studies in health care delivery without learning who the patients are;
• And we may disclose your medical information to another provider who has a relationship with you and is subject to the same Privacy rules, for their health care operation purposes.

On Your Authorization: You may give us written authorization to use your medical information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your medical information for any reason except those described in this notice.

Appointment Reminders: We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at the hospital.

To Your Family and Friends: Unless you object, we may disclose your medical information to a family member, friend or other person to the extent necessary to help with your health care or with payment for your health care. If you are not present, or in the event of your incapacity or an emergency, we will disclose your medical information based on our professional judgment of whether the disclosure would be in your best interest. We will also use our professional judgment and our experience with common practice to allow a person to pick up filled prescriptions, medical supplies, x-rays or other similar forms of medical information.

Hospital Directory: We may use your name, your location in our facility, your general medical condition, and your religious affiliation in our facility directories. We will disclose this information to members of the clergy and, except for religious affiliation, to other persons who ask for you by name. We will provide you with an opportunity to restrict or prohibit some or all disclosures for facility directories unless emergency circumstances prevent your opportunity to object.

In addition, we may disclose medical information about you to an organization assisting in a disaster relief effort so your family can be notified about your condition and location.

By Law or Special Circumstances: We may use or disclose your medical information as authorized by law for the following purposes deemed to be in the public interest or benefit:

• as required by law;for public health activities, including disease and vital statistic reporting, child abuse reporting, FDA oversight, and to employers regarding work-related illness or injury;
• to report adult abuse, neglect, or domestic violence;
• to health oversight agencies;In response to court and administrative orders and other lawful processes;
• to law enforcement officials after receiving subpoenas and other lawful processes, concerning crime victims, suspicious deaths, crimes on our premises, reporting crimes in emergencies, and for purposes of identifying or locating a suspect or other person;
• to coroners, medical examiners, and funeral directors;
• to organ procurement organizations;
• to avert a serious threat to health or safety;
• in connection with certain research activities;
• to the military and to federal officials for lawful intelligence, counterintelligence, and national security activities;
• to correctional institutions regarding inmates;
• and as authorized by state worker's compensation laws

Health Related Benefits and Services: We may use your medical information to contact you with information about health-related benefits and services or about treatment alternatives that may be of interest to you. We may disclose your medical information to a business associate to assist us in these activities.

We may use or disclose your medical information to encourage you to purchase or use a product or service by face-to-face communication or to provide you with promotional gifts.

Use and Disclosure of Certain Types of Medical Information: For certain types of medical information we may be required to protect your privacy in ways more strict than we have discussed in this notice. We must abide by the following rules for our use or disclosure of certain types of your medical information:

HIV Information: We may not disclose HIV information unless required by law, pursuant to an authorization or the disclosure is to you or your personal representative; to medical personnel in an emergency to the extent necessary to protect your health or safety; to a person whom the facility believes has been exposed to HIV infection, but only such information shall be disclosed as related to HIV information; or, to a law enforcement officer who has in the course of his or her duties been exposed to your blood or bodily fluid in such a manner that risk of infection exists, but only such information shall be disclosed as related to HIV information or the hepatitis B virus.

Alcohol and Drug Abuse Information: We may not disclose your medical information that contains alcohol and drug abuse information except to you, your personal representative or pursuant to an authorization or as may otherwise be allowed by law.

Your Rights Regarding Medical Information About You

Right to Inspect and Copy: You have the right to look at or get copies of your medical information, with limited exceptions. You must make a request in writing to obtain access to your medical information. You may obtain a form to request access by using the contact information listed at the end of this notice. You may also request access by sending us a letter to the address at the end of this notice. If you request copies, we will charge you a fee for copying and postage if you want the copies mailed to you. Contact us using the information listed at the end of this notice for a full explanation of our fee structure.

We may deny your request to inspect and copy in very limited circumstances as allowed by law. If you are denied access to your 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.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your medical information for purposes other than treatment, payment, health care operations, as authorized by you, and for certain other activities, since April 14, 2003. You must make a request in writing to request a listing of disclosures. You may obtain a form to request the accounting by using the contact information at the end of this notice.

If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. Contact us using the information listed at the end of this notice for a full explanation of our fee structure.

Restriction: You have the right to request that we place certain restrictions on our use or disclosure of your medical information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Any agreement to additional restrictions must be in writing. You may obtain a form to request additional restrictions on the use or disclosure of your medical information by using the contact information listed at the end of this notice. We will not be bound to the restrictions unless our agreement is signed by you and the appropriate hospital representative.

Confidential Communication: You have the right to request that we communicate with you about your medical information by alternative means or to alternative locations. For example, you might request that we contact you at work or by mail. You must make your request in writing. You may obtain a form to request alternative communications by using the contact information listed at the end of this notice. We must accommodate your request if it is reasonable, specifies the alternative means or location, and provides satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. Your request must be in writing, and it must explain why the information should be amended. You may obtain a form to request an amendment by using the contact information listed at the end of this notice. We may deny your request if we did not create the information you want amended and the individual who provided the information remains available or for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement to be attached to the information you wanted amended. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information.

Electronic Notice: If you receive this notice on our web site or by electronic mail (e-mail), you are entitled to receive this notice in written form. Please contact us using the information listed at the end of this notice to obtain this notice in written form.

Questions and Complaints

If you want more information about our privacy practices or have questions or concerns, please contact us using the information listed at the end of this notice.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your medical information or in response to a request you made to amend or restrict the use or disclosure of your medical information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your medical information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact

Privacy Officer
Southampton Hospital
240 Meeting House Lane
Southampton, New York 11968
Telephone: (631) 726-8200

THIS NOTICE IS YOUR COPY TO RETAIN FOR ANY FUTURE QUESTIONS OR CONCERNS REGARDING THE USE OF YOUR PROTECTED HEALTH INFORMATION.