Please Review It Carefully.


This notice describes St. Mary's Medical Center practices and that of:

  • Any physician or health care professional authorized to enter or access information in your medical record.
  • Participants in an affiliated health care education program.
  • All departments and units of this facility.
  • All employees and associated health care personnel
  • Any member of a volunteer group we allow to help you while you are receiving our services.
  • Any affiliate engaged in the provision of health care services on behalf of this facility.

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


We understand that medical information about you and your health is personal.  We are committed to protecting medical information about you.  To provide you with quality care and to comply with certain legal requirements, we create a record of the care and services you receive.  This notice applies to all of the medical records of your care generated at our facility, whether made by our personnel or your personal physician.  Your personal physician may have different policies or notices regarding his/her use and disclosure of your medical information created in the physician's office or clinic.


  • Make sure that medical information that identifies you (otherwise known as protected health information or PHI) is kept private;
  • Give you this notice of our legal duties and privacy practices with respect to PHI about you; and
  • Follow the terms of the notice that is currently are in effect.


The following categories describe different ways that we use and disclose PHI.  Not every use or disclosure in a category is listed.

For Health Care Services.  We may use PHI about you to provide you with health care services.  We may disclose PHI about you to physicians, nurses, social workers, technicians, medical students, and/or students participating in health care education, or other health care personnel who are involved in taking care of you during your need for health care services.  Our different departments also may share PHI about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays.  In order to coordinate and continue your care we may also disclose PHI about you to external entities who may be involved in your medical care after you leave our facility.

For Payment.  We may use and disclose PHI about you so that the health care services you receive from us may be billed to and payment may be collected from you, an insurance company or a third party.  We may also tell your health plan about health care services you are going to receive to obtain prior approval or to determine whether your plan will cover the health care services.

For Health Care Operations.  We may use and disclose PHI about you for health care operations.  For example, we may use PHI to review our health care services and to evaluate the performance of our staff in caring for you.  We may use and disclose PHI to contact you as a reminder that you have an appointment for health care services or medical care

Business Associates.  We may use or disclose PHI about you to an outside company that assists us with health care operations, including, but not limited to services such as (billing or medical transcription service.) These outside companies are called “business associates.”  These companies may create or receive PHI on our behalf.  When this is necessary, we will require them to appropriately safeguard any information disclosed to them during the performance of their service.

Health-Related Benefits and Services.  We may use and disclose PHI to tell you about possible health care services, health-related benefits, or services that may be of interest to you.  For instance, you may receive mail containing marketing information pertinent to your healthcare.

Health Care Facility Directory.  Unless you notify us that you object, we may include certain limited information about you in the health care facility directory while you are a patient at the facility.  This information may also be provided to members of the clergy.  The information may include your name, location in the health care facility and, your general condition (e.g., fair, stable, etc.).  You may request that no information contained in the directory be disclosed.  In emergency circumstances, if you are unable to communicate your preference, you may be listed in the directory.

Notification & Communication With Family.  If you agree, do not object, or we reasonably infer that there is no objection, we may disclose PHI about you to a family member, personal representative or other person identified by you who is involved in your health care or payment for your health care.  If you are not present, are incapacitated, or it is an emergency or disaster relief situation, we will use our professional judgment to determine whether disclosing limited PHI is in your best interest under the circumstances.  We may disclose PHI to a family member, personal representative or other person responsible for health care or payment for health care of a deceased individual if not inconsistent with the prior expressed preferences of the individual that are known to us.  You also have the right to request a restriction on our disclosure of your PHI to someone who is involved in your care.

Research.  Under certain circumstances, we may use and disclose PHI about you for research purposes.  All research projects, however, are subject to a special approval process.  This process evaluates a proposed research project and its use of PHI, trying to balance the research needs with patients' need for privacy of their PHI.  In some instances, the law allows us to do some research using PHI about you without your approval.

Fundraising.  Under certain circumstances, we may use and disclose your information for fundraising purposes.  Any fundraising disclosures are limited to demographic information and the date(s) health care services were received and  are provided only to business associates or institutionally – related foundations.  If you do not wish to be contacted by the facility or its affiliates regarding fundraising, you may opt out.

As Required By Law.  We will disclose PHI about you when required to do so by federal, state or local law or in response to a valid subpoena.

To Avert A Serious Threat to Health or Safety.  Consistent with applicable laws, we may use and disclose PHI about you when necessary to prevent  or lessen a serious  and imminent 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 to help prevent the threat.  We may also disclose PHI about you if it is necessary for law enforcement authorities to identify or apprehend an individual.

Organ and Tissue Donation.  If you are an organ donor, we may release PHI 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.

News Media.  Sometimes, the circumstances that brought you to the hospital are of interest to the media.  SMMC will use the terms, “good”, “fair”, “serious” or “critical” to indicate a patient's condition without sharing specific PHI.

Lawsuits and Other Legal Proceedings.  We may disclose PHI about you in the course of any judicial or administrative proceeding or in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized).  If certain conditions are met, we may also disclose PHI about you in response to a subpoena, a discovery request, or other lawful process.

Law Enforcement.  Under certain conditions, we may disclose PHI about you to law enforcement officials for law enforcement purposes.  these law enforcement purposes include, but are not limited to, responding to a court order or similar process; as necessary to locate or identify a suspect, fugitive, material witness, or missing person; reporting suspicious wounds, burns or other physical injuries; or as relating to the victim of a crime.

Health Oversight Activities.  We may disclose PHI about you to a health oversight agency for activities authorized by law.  For example, these oversight activities may include audits; investigations; inspection; licensure or disciplinary action; or civil, administrative, or criminal proceedings or actions.  Oversight agencies seeking this information include government agencies that oversee the facility, government benefit programs, other government regulatory programs, and government agencies that ensure compliance with civil rights laws.

Coroners, Medical  Examiners and Funeral Directors.  We may release PHI about you to a coroner or medical examiner.  This may be necessary, for example, to identify a deceased person or to determine the cause of death.  We may also release PHI about you to a funeral director, as necessary, or to carry out his/her duties.

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

Workers' Compensation.  We may release PHI about you, following a written request by your employer, worker’s compensation insurer, or their representative, for workers' compensation or similar programs.  These programs provide benefits for work-related injuries or illness.

Employer Sponsored Health and Wellness Service.  We may maintain PHI about employer sponsored health and wellness services we provide our patients, including services provided at their employment site.  We will use the PHI to provide you medical treatment or services and will disclose the information about you to others who provide you medical care.

Public Health Risks.  We may disclose medical information about you for public health activities.  These activities generally include the following;

  • to prevent or control disease, injury or disability;
  • to report births and deaths;
  • to report child abuse or neglect;
  • to report reactions to medications or problems with products; to notify people of recalls of products they may be using;
  • 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;
  • to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence

Shared Medical Record/Health Information Exchanges.  We maintain PHI about our patients in shared medical records that allow our business Associates to share HI.  We may also participate in various electronic health information exchanges that facilitate access to PHI by other health care providers who provide you care.  For example, if you are admitted on an emergency basis to another hospital that participates in the health information exchange, the exchange will allow us to make your PHI available electronically to those who need it to treat you.

We will only make this disclosure if you agree or when required or authorized by law.

Most uses and disclosures of psychotherapy notes, uses and disclosures of PHI for marketing purposes and disclosures that constitute the sale of PHI require your written authorization.

Other uses and disclosures of your PHI that are not described above will be made only with your written authorization.  If you provide St. Mary’s Medical Center with an authorization, you may revoke the authorization in writing, and this revocation will be effective for future uses and disclosure of PHI.  However, the revocation will not be effective for information that we have used or disclosed in reliance on the authorization.


You have the following rights regarding PHI we maintain about you:

Right to Access of Your Own Health Information.  You have the right to inspect and copy most of your PHI for as long as we maintain it as required by law.  All requests for access must be made in writing.  We may charge you a fee for each page copied and postage if applicable.  You also have the right to ask for a summary of this information.  If you request a summary, we may charge you a nominal fee.

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.

Right to Inspect and Copy.  You have the right to inspect and copy PHI that may be used to make decisions about your care.

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 us. 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:

  • Was not created by us;
  • Is not part of the medical information kept by or for us;
  • Is not part of the information which you would be permitted to inspect and copy; or
  • Is accurate and complete

If we deny your request, we will provide you a written explanation.  You may respond with a statement of disagreement to be appended 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 your name, of the amendment and to include the changes in any future disclosures of that information.    

Right to Accounting of Disclosures.  You have the right to request an "accounting of disclosures."  This is a list of the disclosures we made of PHI about you.

Right to Request Confidential Communication.  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.

Right to be Notified of a Breach.  You have the right to be notified in the event that we (or one of our Business Associates) discover a breach of unsecured PHI involving your medical information.

Right to Request Restrictions.  You have the right to request a restriction or limitation on the PHI we use or disclose about you for health care services, payment or health care operations.  You also have the right to request a limit on the PHI 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.  You could also ask to be excluded from surveys pertaining to patient satisfaction.

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 with emergency health care services.

We will agree to restrict disclosure of PHI about an individual to a health plan if the purpose of the disclosure is to carry out payment or health care operations and the PHI pertains solely to a service for which the individual, or a person other than the health plan, has paid us for in full.  For example, if a patient pays for a service completely out of pocket and asks us not to tell his/her insurance company about it, we will abide by this request. 

To request restrictions, you must make your request in writing.  In your request, you must tell us (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.


If you have questions or wish to inspect, amend or restrict your PHI, you may contact the Health Information Department at (304) 526-1205.

If you feel your privacy rights have been violated, you may contact our Privacy Officer at (304) 526--1912.  You may also file a complaint with the Secretary of  the U.S. Department of Health and Human Services.  There will be no retaliation for filing a complaint.