NOTICE OF PRIVACY PRACTICES OF ST. CLARE'S HOSPITAL OF SCHENECTADY, N.Y., THE MEMBERS OF THE HOSPITAL'S MEDICAL-DENTAL STAFF AND THE HOSPITAL'S ALLIED HEALTH PROFESSIONALS

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 IT CAREFULLY.

A. BACKGROUND

We - - that is St. Clare's Hospital, the members of its Medical-Dental Staff and its Allied Health Professionals - - have a legal duty to protect the privacy of health information that may reveal your identity and provide you with a copy of this Notice. We will use and disclose your protected health information only as disclosed in this Notice. We may change this Notice at any time. A complete copy of the current Notice will always be posted in the Hospital. You will also be able to obtain a current copy of this Notice by accessing the Hospital's Web site at www.stclares.org, by calling the St. Clare's Hospital Executive Office at (518) 347-5606, or asking for one at the time of your next visit to the Hospital. If you have any questions about this Notice or would like further information, please contact the St. Clare's Hospital Executive Office at (518) 347-5606.

B. DEFINITIONS

1. Protected health information" or PHI" means any information, whether oral or recorded in any form or medium created or received at the Hospital that:

a. relates to the physical or mental health of an individual, the provision of healthcare to an individual, or the payment for the provision of healthcare to an individual; and
b. identifies or can be used to identify the individual. Protected health information does not include information that has been de-identified as described in Section C.1 of this Notice, or information in the Hospital employment records. Some examples of protected health information are:

• information about your health condition (such as a disease you may have);
• information about healthcare services you have received or may receive in the future (such as an operation);
• information about your healthcare benefits under an insurance plan (such as whether a prescription is covered);
• geographic information (such as where you live or work);
• demographic information (such as your race, gender, ethnicity, or marital status);
• unique numbers that may identify you (such as your social security number, your phone number, or your driver's license number); and other types of information that may identify who you are.

2. This Notice of Privacy Practices governs how the:

• Hospital and its employees;
• members of the Hospital's Medical-Dental Staff; and
• members of the Hospital's Allied Health Professionals

will use or disclose PHI that was received or created by any of them at the Hospital. As used in this Notice, the phrases "we", "our" or "us" refers to the Hospital, its employees, its Medical-Dental Staff and its Allied Health Professionals. This Notice of Privacy Practices does not govern the actions of the Hospital's Medical-Dental Staff or its Allied Health Professionals with respect to health information that was not created or received at the Hospital. For example, health information that was created or obtained by your physician in his/her private office.

C. USE AND DISCLOSURE OF YOUR PHI

1. In general, we will obtain your written authorization before using your PHI or sharing it with others outside the Hospital. There are some situations when we do not need your written authorization before using your PHI or sharing it with others. Those situations are as follows:

Treatment. We may share your PHI with doctors or nurses and other individuals in the Hospital who are involved in taking care of you, and they may in turn use that information to diagnose or treat you. A doctor at the Hospital may share your PHI with other healthcare providers inside the Hospital or with healthcare providers outside the Hospital, to determine how to diagnose or treat you. We may also share your PHI with healthcare providers to whom you have been referred for further healthcare.

Payment. We may use your PHI or share it with others so that we obtain payment for your healthcare services. For example, we may share information about you with your health insurance company in order to obtain reimbursement after we have treated you. In some cases, we may share information about you with your health insurance company to determine whether it will cover your treatment. We might also need to inform your health insurance company about your health condition in order to obtain pre-approval for your treatment, such as admitting you to the Hospital for a particular type of surgery.

Healthcare Operations. Each of the entities covered by this Notice may use your PHI or share it with others in order to conduct their healthcare business operations. For example, an entity covered by this Notice may use your PHI to evaluate the performance of its staff in caring for you, or to educate its staff on how to improve the care they provide for you. It may also share your PHI with another company that performs business services for the entity, such as billing companies. If so, the entity that shares your PHI will have a written contract to ensure that this company also protects the privacy of your PHI. Each of the entities covered by this Notice may also disclose your PHI to other healthcare providers for the purpose of that provider's healthcare operations if each of the involved entities either has or had a relationship with you, the PHI pertains to that relationship, and the disclosure is either for the purpose of healthcare fraud and abuse detection or compliance; or used in efforts to improve the way care is delivered to you by the provider or its staff.

Appointment Reminders, Treatment Alternatives, Benefits and Services. We may use your PHI when we contact you with a reminder that you have an appointment for treatment or services at our facility. We may also use your PHI in order to recommend possible treatment alternatives or health-related benefits and services that may be of interest to you.

Fundraising. We may use information about where you live or work, and the dates that you received treatment, in order to contact you to raise money to help us operate. We may also share this information with a charitable foundation that will contact you to raise money on our behalf. If you do not want to be contacted for these fundraising efforts, please write to the St. Clare's Hospital Executive Office, 600 McClellan Street, Schenectady, NY 12304.

Information That Does Not Identify You. We may use or disclose your PHI if we have removed any information that might reveal who you are. This is known as "de-identified" information.

1. Hospital Directory/ Friends and Family

We may use limited portions of your PHI in the Hospital's Directory or share it with friends and family involved in your care, without your written authorization or consent. We will always give you an opportunity to object unless there is insufficient time because of a medical emergency (in which case we will discuss your preferences with you as soon as the emergency is over). We will follow your wishes unless we are required by law to do otherwise.

Hospital Directory. If you do not object, we will include your name, your location in the Hospital, your general condition (e.g., fair, stable, critical, etc.) and your religious affiliation in the Hospital's Directory while you are a patient in the Hospital. This 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 he or she doesn't ask for you by name.

Friends and Family Involved in Your Care. If you do not object, we may disclose your PHI to a family member, personal representative, or close personal friend who is involved in your care or payment for that care. We may also notify a family member, personal representative or another person responsible for your care about your location and general condition at the Hospital, or about the unfortunate event of your death. In some cases, we may need to share your information with an organization that will help us notify these persons.

3. Emergencies or Public Need

We may use your PHI, and share it with others, in order to treat you in an emergency or to meet important public needs. We will not be required to obtain your written authorization, consent or any other type of permission before using or disclosing your information for these reasons. Emergencies. We may use or disclose your PHI if you need emergency treatment or if we are required by law to treat you but are unable to obtain your consent. If this happens, we will try to obtain your consent as soon as we reasonably can after we treat you.

Communication Barriers. We may use and disclose your PHI if we are unable to obtain your consent because of substantial communication barriers, and we believe you would want us to treat you if we could communicate with you.

As Required By Law. We may use or disclose your PHI if we are required by law to do so. We also will notify you of these uses and disclosures if notice is required by law.

Public Health Activities. We may disclose your PHI to authorized public health officials (or a foreign government agency collaborating with such officials) so they may carry out their public health activities. For example, we may share your PHI with government officials that are responsible for controlling disease, injury or disability. We may also disclose your PHI to a person who may have been exposed to a communicable disease or be at risk for contracting or spreading the disease if a law permits us to do so. And finally, we may release some PHI about you to your employer if your employer hires us to provide you with a physical exam and we discover that you have a work-related injury or disease that your employer must know about in order to comply with employment laws.

Victims of Abuse, Neglect or Domestic Violence. We may disclose your PHI to a public health authority to whom we are required to make reports of abuse, neglect or violence. For example, we may report your PHI to government officials if we reasonably believe that a patient has been a victim of child abuse or neglect; a gunshot wound; a serious burn or stabbing or domestic violence. In some cases we may be required or authorized to act without your permission.

Health Oversight Activities. We may release your PHI to government agencies authorized to conduct audits, investigations, and inspections of the Hospital. These government agencies monitor the operation of the healthcare system, government benefit programs such as Medicare and Medicaid, and compliance with government regulatory programs and civil rights laws.

Product Monitoring, Repair and Recall. We may disclose your PHI to a person or company that is required by the Food and Drug Administration to: (1) report or track product defects or problems; (2) repair, replace, or recall defective or dangerous products; or (3) monitor the performance of a product after it has been approved for use by the general public.

Lawsuits and Disputes. We may disclose your PHI if we are ordered to do so by a court that is handling a lawsuit or other dispute or if we receive a subpoena and we receive satisfactory assurances that you had adequate notice of and an opportunity to object to the subpoena.

Law Enforcement. We may disclose your PHI to law enforcement officials for the following reasons:

• To comply with court orders or laws that we are required to follow;
• To assist law enforcement officers with identifying or locating a suspect, fugitive, witness, or missing person;
• If you have been the victim of a crime and we determine that: (1) we have been unable to obtain your consent because of an emergency or your incapacity; (2) law enforcement officials need this information immediately to carry out their law enforcement duties; and (3) in our professional judgment disclosure to these officers is in your best interests;
• If we suspect that your death resulted from criminal conduct;
• If necessary to report a crime that occurred on our property; or
• If necessary to report a crime discovered during an offsite medical emergency (for example, by emergency medical technicians at the scene of a crime).

To Avert a Serious Threat to Health or Safety. We may use your PHI or share it with others when necessary to prevent a serious threat to your health or safety, or the health or safety of another person or the public. In such cases, we will only share your information with someone able to help prevent the threat. We may also disclose your PHI to law enforcement officers if you tell us that you participated in a violent crime that may have caused serious physical harm to another person (unless you admitted that fact while in counseling), or if we determine that you escaped from lawful custody (such as a prison or mental health institution).

National Security and Intelligence Activities or Protective Services. We may disclose your PHI to authorized federal officials who are conducting national security and intelligence activities or providing protective services to the President or other important officials.

Military and Veterans. If you are in the Armed Forces, we may disclose PHI about you to appropriate military command authorities for activities they deem necessary to carry out their military mission. We may also release PHI about foreign military personnel to the appropriate foreign military authority.

Inmates and Correctional

Institutions. If you are an inmate or you are detained by a law enforcement officer, we may disclose your PHI to the prison officers or law enforcement officers if necessary to provide you with healthcare, or to maintain safety, security and good order at the place where you are confined. This includes sharing information that is necessary to protect the health and safety of other inmates or persons involved in supervising or transporting inmates.

Workers' Compensation. We may disclose your PHI for workers' compensation or similar programs that provide benefits for work-related injuries.

Coroners, Medical Examiners and Funeral Directors. In the unfortunate event of your death, we may disclose your PHI to a coroner or medical examiner. This may be necessary, for example, to determine the cause of death. We may also release this information to funeral directors as necessary to carry out their duties.

Organ and Tissue Donation. In the unfortunate event of your death, we may disclose your PHI to organizations that procure or store organs, eyes or other tissues so that these organizations may investigate whether donation or transplantation is possible under applicable laws.

Research. In most cases, we will ask for your written authorization before using your PHI or sharing it with others in order to conduct research. However, under some circumstances, we may use and disclose your PHI without your authorization if we obtain approval through a special process to ensure that research without your authorization poses minimal risk to your privacy. Under no circumstances, however, would we allow researchers to use your name or identity publicly. We may also release your PHI without your authorization to people who are preparing a future research project, so long as any information identifying you does not leave our facility. In the unfortunate event of your death, we may share your PHI with people who are conducting research using the information of deceased persons, as long as they agree not to remove from our facility any information that identifies you.

D. USES AND DISCLOSURES WITH YOUR AUTHORIZATION

In addition to the uses and disclosures above, we can use or disclose your PHI for any other purpose, if you give us your written, signed authorization to use or disclose the information for that specific purpose. For example, you may give us an authorization to give information to a prospective employer as part of a pre-employment physical.

E. YOUR RIGHTS TO ACCESS AND CONTROL YOUR HEALTH INFORMATION

We want you to know that you have the following rights to access and control your PHI. These rights are important because they will help you make sure that the PHI we have about you is accurate. They may also help you control the way we use your information and share it with others, or the way we communicate with you about your medical matters.

1. Right To Inspect and Copy Records

You have the right to inspect and obtain a copy of any of your PHI that may be used to make decisions about you and your treatment for as long as we maintain this information in our records. This includes medical and billing records. To inspect or obtain a copy of your PHI, please submit your request in writing to the Medical Records Department, St. Clare's Hospital, 600 McClellan Street, Schenectady, NY 12304. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies we use to fulfill your request. The standard fee is $ .75 per page and must generally be paid before or at the time we give the copies to you. Under federal and state law, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. In some circumstances you may have a right to have this decision reviewed. Contact the St. Clare's Hospital Executive Office at (518) 347-5606 if you have questions about this.

Under certain very limited circumstances, we may deny your request to inspect or obtain a copy of your information. If we do, we will provide you with a summary of the information instead. We will also provide a written notice that explains our reasons for providing only a summary, and a complete description of your rights to have that decision reviewed and how you can exercise those rights. The notice will also include information on how to file a complaint about these issues with us or with the Secretary of the Department of Health and Human Services. If we have reason to deny only part of your request, we will provide complete access to the remaining parts after excluding the information we cannot let you inspect or copy.

2. Right To Amend Records

If you believe that the PHI 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 in our records. To request an amendment, please write to the St. Clare's Hospital Executive Office, 600 McClellan Street, Schenectady, NY 12304. Your request should include the reasons why you think we should make the amendment.

If we deny all or part of your request, we will provide a written notice that explains our reasons for doing so. You will have the right to have certain information related to your requested amendment included in your records. For example, if you disagree with our decision, you will have an opportunity to submit a statement explaining your disagreement, which we will include in your records. We will also include information on how to file a complaint with us or with the Secretary of the Department of Health and Human Services. These procedures will be explained in more detail in any written denial notice we send you.

3. Right To an Accounting of Disclosures

After April 14, 2003, you have a right to request an "accounting of disclosures" which is a list with information about how we have shared your information with others. An accounting list, however, will not include:

• Disclosures we made to you;
• Disclosures we made in order to provide you with treatment, obtain payment for that treatment, or conduct our normal business operations;
• Disclosures made in the facility directory;
• Disclosures made to your friends and family involved in your care;
• Disclosures made to federal officials for national security and intelligence activities
• Disclosures about inmates to correctional institutions or law enforcement officers; or
• Disclosures made before April 14, 2003.

To request this list, please write to the St. Clare's Hospital Executive Office, 600 McClellan Street, Schenectady, NY 12304. Your request must state a time period for the disclosures you want us to include. For example, you may request a list of the disclosures that we made between January 1, 2004 and January 1, 2005. You have a right to one list within every 12 month period for free. However, we may charge you for the cost of providing any additional lists in that same 12 month period. We will always notify you of any cost involved so that you may choose to withdraw or modify your request before any costs are incurred.

In rare cases, we may have to delay providing you with the accounting list without notifying you because a law enforcement official or government agency has asked us to do so.

4. Right To Request Additional Privacy Protections

You have the right to request that we further restrict the way we use and disclose your PHI to treat your condition, collect payment for that treatment, or run our normal healthcare business operations. You may also request that we limit how we disclose information about you to family or friends involved in your care. For example, you could request that we not disclose information about a surgery you had. To request restrictions, please write to the St. Clare's Hospital Executive Office, 600 McClellan Street, Schenectady, NY 12304. Your request should include (1) what information you want to limit; (2) whether you want to limit how we use the information, how we share it with others, or both; and (3) to whom you want the limits to apply.

We are not required to agree to your request for a restriction, and in some cases the restriction you request may not be permitted under law. However, if we do agree, we will be bound by our agreement unless the information is needed to provide you with emergency treatment or comply with the law. Once we have agreed to a restriction, you have the right to revoke the restriction at any time. Under some circumstances, we will also have the right to revoke the restriction as long as we notify you before doing so; in other cases, we will need your permission before we can revoke the restriction.

5. Right To Request Confidential Communications

You have the right to request that we communicate with you about your medical matters in a more confidential way. For example, you may ask that we contact you at work instead of at home. To request more confidential communications, please write to the St. Clare's Hospital Executive Office, 600 McClellan Street, Schenectady, NY 12304. We will try to accommodate all reasonable requests. Please specify in your request how or where you wish to be contacted, and how payment for your healthcare will be handled if we communicate with you through this alternative method or location.

6. Right to File a Complaint

You have the right to file a complaint if you believe your privacy rights have been violated. You may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, please contact the St. Clare's Hospital Executive Office at (518) 347-5606. No one will retaliate or take action against you for filing a complaint.

7. Personal Representation

You have the right to name a personal representative who may act on your behalf to control the privacy of your PHI. Parents and guardians will generally have the right to control the privacy of PHI about minors unless the minors are permitted by law to act on their own behalf.

8. Special Protections for HIV, Alcohol and Substance Abuse, Mental Health and Genetic Information

Special privacy protections apply to HIV-related information, alcohol and substance abuse information, mental health information, and genetic information. Some parts of this general Notice of Privacy Practices may not apply to these types of information. If your treatment involves this information, you will be provided with separate notices explaining how the information will be protected. To request copies of these other notices now, please contact the St. Clare's Hospital Executive Office at (518) 347-5606.

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

 I hereby acknowledge receipt of the Notice of Privacy Practices for St. Clare's Hospital of Schenectady, N.Y., the Members of its Medical-Dental Staff and its Allied Health Professionals.

Name:

Date:

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