I. Understanding Your Health Record/information
Each time you visit Sac and Fox Nation Health Services facility for services, a record of your visit is made. If you are referred by the Sac and Fox Nation Health Services through the Contract Health Service (CHS) program, Sac and Fox Nation Health Services also keeps a record of your CHS visit. Typically, this record contains your symptoms, examination, test results, diagnoses, treatment, and a plan for future care. This information, often referred to as your health record, serves as a:
• Plan for your care and treatment
• Communication source between health care professionals
• Tool with which we can check results and continually work to improve the care we provide
• Means by which Medicare, Medicaid or private insurance payers can verify the services billed
• Tool for education of health care professionals
• Source of information for public health authorities charged with improving the health of the people
• Source of data for medical research, facility planning and marketing
• Legal document that describes the care you receive

Understanding what is in your health record and how the information is used helps you to:
• Ensure its accuracy
• Better understand why others may review your health information
• Make an informed decision when authorizing disclosures

II. Your Health Information Rights
Although your health record is the physical property of the Sac and Fox Nation Health Services, the information belongs to you.

You have the right to:
• Inspect and receive a copy of your health record
• Request a restriction on certain uses and disclosures of your health information. For example, you may ask that we not disclose your health information and or treatment to a family member. Sac and Fox Nation Health Services is not required to agree to your request; but if we do, we will comply with your request unless the information is needed to provide you with emergency services.
• Request a correction/amendment to your health record if you believe that health information we have about you is incorrect or incomplete; we may amend your record or include your statement of disagreement.
• Request confidential communications about your health information. You may ask that we communicate with you at a location other than your home or by a different means of communications such as telephone or mail.
• Receive a listing of certain disclosures Sac and Fox Nation Health Services has made of your health information upon request. This information is maintained for six years or the life of the record, whichever is longer.
• Revoke your written authorization to use or disclose health information. This does not apply to health information already disclosed or used or in circumstances where we have taken action on your authorization or the authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim under the policy or the policy itself.
• Obtain a paper copy of the Sac and Fox Nation Health Services Notice of Privacy Practices upon request

III. Sac and Fox Nation Health Services Responsibilities
The Sac and Fox Nation Health Services is required by law to:
• Maintain the privacy of your health information
• Inform you about our privacy practices regarding health information we collect and maintain about you
• Notify you if we are unable to agree to a requested restriction
• Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.
• Honor the terms of this notice or any subsequent revisions of this notice.

Sac and Fox Nation Health Services reserves the right to change its privacy practices and to make the new provisions effective for all protected health information it maintains. If Sac and Fox Nation Health Service makes any significant changes to this Notice, it will send you a copy within 60 days. Sac and Fox Nation Health Services also will post any revised Notice of Privacy Practices at public places in its health care facilities and you may also request a copy of the notice.

Sac and Fox Nation Health Services understand that health information about you is personal and is committed to protecting your health information. Sac and Fox Nation Health Services will not use or disclose your health information without your permission, except as described in this notice.

IV. How Sac and Fox Nation Health Services may use and disclose health information about you.

The following categories describe how we may use and disclose health information about you.

We will use and disclose your health information to provide you treatment.
• For example: Your personal information will be recorded in your health record and used to determine the course of treatment for you. Your health care provider will document in your health record her/his instructions to members of your healthcare team. The actions taken and the observations made by the members of your healthcare team will be recorded in your health record so your health care provider will know how you are responding to treatment.

If Sac and Fox Nation Health Services refers you to another health care facility under the Contract Health Services (CHS) program, Sac and Fox Nation Health Services may disclose you health information to that health care provider for treatment decisions.

If you are transferred to another facility for further care and treatment Sac and Fox Nation Health Services may disclose information to that facility to enable them to know the extent of treatment you have received and other information about your condition.

Your health care provider(s) may give copies of your health information to others to assist in your treatment.

We will use and disclose your health information for payment purposes.
• For example: If you have private insurance, Medicare, or Medicaid coverage, a bill will be sent to your health plan for payment. The information on or accompanying the bill will include information that identities you, as well as your diagnosis, procedures, and supplies used for your treatment.

If Sac and Fox Nation Health Services refers you to another health care provider under the Contract Health Services (CHS) program, Sac and Fox Nation Health Services may disclose your health information with that provider for health care payment purposes.

We will use and disclose your health information health care operations.
• For example: We may use your health information to evaluate your care and treatment outcomes with our quality improvement team. This information will be used to continually improve the quality and effectiveness of the services we provide. This includes health care services provided under Contract Health Services (CHS) program.

Business Associates
Sac and Fox Nation Health Services provides some health care services and related functions through the use of contracts with business associates. For example, Sac and Fox Nation Health Services may have contracts for medical transcription. When these services are contracted, Sac and Fox Nation Health Services may disclose your health information to business associates so that they can perform their jobs. We require our business associates to protect and safeguard your health information in accordance with all applicable federal laws.

Directory
If you are admitted to a Sac and Fox Nation Health Service facility, Sac and Fox Nation Health Services may use or disclose your name, general condition, religious affiliation, and location within our facility, for facility directory purposes, unless you notify us that you object to this information being listed. Sac and Fox Nation Health Services may provide your religious affiliation only to members of the clergy.

Notification
Sac and Fox Nation Health Services may use or disclose your health information to notify or assist in the notification of a family member, personal representative or other authorized person(s) responsible for your care, unless you notify us that you object.

Communication with Family
Sac and Fox Nation Health Services health providers may use or disclose your health information to others responsible for your care unless you object. For example, Sac and Fox Nation Health Services may provide your family members, other relatives, close personal friends or any other person you identify with health information which is relevant to that person's involvement with your care or payment for such care.

Interpreters
In order to provide you proper care and services, Sac and Fox Nation Health Services may use the services of an interpreter. This may require the use or disclosure of your personal health information to the interpreter.

Research
Sac and Fox Nation Health Services may use or disclose your health information for research purposes that has been approved by a Sac and Fox Nation Health Service Institutional Review Board (IRB) that has reviewed the research proposal and established protocols to ensure the privacy of your health information. Sac and Fox Nation Health Services may also use or disclose your health information for research purposes based on your written authorization.

Uses and Disclosures about Decedents
Sac and Fox Nation Health Services may use or disclose health information about decedents to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death, or other duties as authorized by law. Sac and Fox Nation Health Services also may disclose health information to funeral directors consistent with applicable law as necessary to carry out their duties.

Organ Procurement Organizations
Sac and Fox Nation Health Services may use or disclose your health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of facilitating organ, eye or tissue donation and transplant.

Treatment Alternatives and Other Health-related Benefits and Services
Sac and Fox Nation Health Services may contact you to provide information about treatment alternatives or other types of health-related benefits and services that may be of interest to you. For example: we may contact you about the availability of new treatment or services for diabetes.

Appointment Reminders
Sac and Fox Nation Health Services may contact you with a reminder that you have an appointment for medical care at Sac and Fox Nation Health Services facility or to advise you of a missed appointment.

Food and Drug Administration (FDA)
Sac and Fox Nation Health Services may use or disclose your health information to the FDA in connection with an FDA-regulated product or activity. For example: we may disclose to the FDA information concerning adverse events involving foods dietary supplements, product defects or problems, and information needed to track FDA-regulated products or to conduct product recalls, repairs, replacements, or look backs (including locating people who have received products that have been recalled or withdrawn), or post marketing surveillance.

Workers Compensation
Sac and Fox Nation Health Services may use or disclose your health information for workers compensation purposes as authorized or required by law.

Public Health
Sac and Fox Nation Health Services may use or disclose your health information to public health or other appropriate government authorities as follows: (1) Sac and Fox Nation Health Services may use or disclose your health information to government authorities that are authorized by law to collect or receive such information for tile purpose of preventing or controlling disease, injury, or disability, or conducting public health surveillance, investigations, and interventions; (2) Sac and Fox Nation Health Services may disclose your health information to government authorities that are authorized by law to receive reports of child abuse or neglect, and (3) Sac and Fox Nation Health Services may disclose your health information to government authorities that are authorized by law to receive reports of other abuse, neglect, or domestic violence as required by law, or as authorized by law if Sac and Fox Nation Health Services believes it is necessary to prevent serious harm. Where authorized by law, Sac and Fox Nation Health Services may disclose your health information to an individual who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition. In some situations Sac and Fox Nation Health Services may disclose to your employer health information concerning a work-related illness or injury or a workplace-related medical surveillance.

Correctional Institution
If you are an inmate of a correctional institution, Sac and Fox Nation Health Services may use or disclose to the institution, health information necessary for your health and the health and safety of other individuals such as officers or employees or other inmates.

Law Enforcement
Sac and Fox Nation Health Services may use or disclose your health information for law enforcement activities as authorized by law or in response to a court of competent jurisdiction Members of the Military: If you are a member of the military services including the Commissioned Cops of the United States Public Health Services, Sac and Fox Nation Health Services may use or disclose your health information if necessary to the appropriate military command authorities as authorized by law.

Health Oversight Authorities
Sac and Fox Nation Health Services may use or disclose your health information to health oversight agencies for activities authorized by law. These oversight activities include: investigations, audits, inspections and other actions. These are necessary for the government to monitor the health care system, government benefit programs, and entities subject to government regulatory programs and/or civil rights laws for which health information is necessary to determine compliance. Sac and Fox Nation Health Services is required by law to disclose protected health information to the Secretary of HHS to investigate or determine compliance with the HIPAA privacy standards.

Compelling Circumstances
Sac and Fox Nation Health Services may use or disclose your health information in certain other situations involving compelling circumstances affecting the health or safety of an individual. For example, in certain circumstances: (1) we may disclose limited protected health information where requested by a law enforcement official for the purpose of identifying or locating a suspect, fugitive, material witness or missing person; (2) if you are believed to be a victim of a crime, a law enforcement official requests information about you and we are unable to obtain your agreement because of incapacity or other emergency circumstances, we may disclose the requested information if we determine that such disclosure would be in your best interests; (3) we may use or disclose protected health information as we believe is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person; (4) we may use or disclose protected health information in the course of judiciary and administrative proceedings if required or authorized by law; (5) we may use or disclose protected health information to report a crime committed on Sac and Fox Nation Health Services facility premises or when Sac and Fox Nation Health Services is providing emergency health care; and (6) we may make any other disclosures that are required by law.

Non Violation of this Notice
Sac and Fox Nation Health Services is not in violation of this Notice or the HIPAA Privacy Rule if any of its employees or its contractors (business associates) discloses protected health information under the following circumstances:
1. Disclosures by Whistleblowers
If a Sac and Fox Nation Health Service employee or contractor (business associate) in good faith believes that Sac and Fox Nation Health Service has engaged in conduct that is unlawful or otherwise violates clinical and professional standards or that the care or services provided by Sac and Fox Nation Health Services has the potential of endangering one or more patients or members of the workplace or the public and discloses such information to:
a. A Public Health Authority or Health Oversight Authority authorized by law to investigate or otherwise oversee the relevant conduct or conditions, or the suspected violation, or an appropriate health care accreditation organization for the purpose of reporting the allegation of failure to meet professional standards or misconduct by Sac and Fox Nation
Health Services; or
b. An attorney on behalf of the workforce member, or contractor (business associate) or hired by the workforce member or contractor (business associate) for the purpose of determining their legal options regarding the suspected violation.

2. Disclosures by Workforce Member Crime Victims
Under certain circumstances, a Sac and Fox Nation Health Service workforce member (either an employee or contractor) who is a victim of a crime on or off the hospital premises may disclose information about the suspect to law enforcement official provided that:
a. The information disclosed is about the suspect who committed the criminal act.
b. The information disclosed is limited to identifying and locating the suspect.

Any other uses and disclosures will be made only with you written authorization, which you may later revoke in writing at any time. (Such revocation would not apply where the health information already has been disclosed or used or in circumstances where Sac and Fox Nation Health Services has taken action in reliance on your authorization or the authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim under the policy or the policy itself.)

To exercise your rights under this Notice, to ask for more information, or to report a problem contact the Health Director at:
Sac and Fox Nation Health Services
Karen Simmons, Interim Health Director
Route 2, Box 247
Stroud, Oklahoma 74079 (918) 968-9531

If believe your privacy rights have been violated, you may tile a written complaint with the above individual(s) or the Secretary of Health and Human Services,
U.S. Department of Health and Human Services
Washington, D.C. 20201.

There will be no retaliation for filing a complaint.
Effective Date: April 14, 2003