Notice of Privacy Practices for Protected Health Information

(Effective: 11/14/14) 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 hospital is permitted by Federal Privacy laws to provide you with a “Notice” of our privacy practices that relate to your medical information. This “Notice” applies to all protected health information/records of your medical care provided by AdventHealth Ottawa and all its employees, staff and volunteers.
If you have any questions about this notice or our privacy practices relating to your health information please contact the following person:

Judy Hintzman
Health Information Management Director/Privacy Officer
1301 South Main Street
Ottawa, Kansas 66067

This “Notice” contains information regarding the following:

  • What is PHI?
  • What are your rights regarding your health information?
  • What are the responsibilities of this facility with regards to your health information?
  • Uses and disclosures of your health information
  • Other Uses and Disclosures – Revoking Previous Permission to Use or Disclose Your Health Information.
  • How to file a complaint regarding your PHI?
  • How to obtain a revised copy if changes are made to this “Notice”?

PHI (Protected Health Information)
Protected health information (PHI) is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services rendered.

Your Rights
The health record and billing records we maintain are the physical property of the hospital. The information contained in the health record, however, belongs to you. You have the following rights:

Right Regarding Electronic Health Information Technology

  • AdventHealth Ottawa participates in electronic health information technology or HIT. This technology allows a provider or a health plan to make a single request through a health information organization or HIO to obtain electronic records for a specific patient from other HIT participants for purposes of treatment, payment, or health care operations. HIOs are required to use appropriate safeguards to prevent unauthorized uses and disclosures.
  • You have two options with respect to HIT. First, you may permit authorized individuals to access your electronic health information through an HIO. If you choose this option, you do not have to do anything.
  • Second, you may restrict access to all of your information through an HIO (except as required by law). If you wish to restrict access, you must submit the required information either online at or by completing and mailing a form. You cannot restrict access to certain information only; your choice is to permit or restrict access to all of your information.
  • Go online if you have questions regarding HIT’s or HIOs, please visit for additional information.
  • If you receive health care services in a state other than Kansas, different rules may apply regarding restrictions on access to your electronic health information. Please communicate directly with your out-of-state health care provider regarding those rules.

Right to an Accounting of Disclosures
You have the right to obtain an “accounting of disclosures” of your health information as required to be maintained by law by delivering a written request to the Health Information Management Director/Privacy Officer by utilizing the form provided to you upon request. Your request must be submitted in writing and state the time period for which you are requesting. This time period cannot exceed 6 years and may not include dates prior to April 14, 2003. Your request should include the form in which you wish to receive the accounting (electronic, paper, etc.). An accounting will not include internal uses of information for treatment, payment, or operations or disclosures of limited data sets (such as statistical data transmitted to the State of Kansas as required by law). We may charge you for the cost of providing this list.

Right to Request Confidential Communications
You may request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our hospital (at the time of registration, or by completing the form and sending it to the Health Information Management Director/Privacy Officer using the form we provide to you upon request. We will consider your request and follow your wishes whenever reasonable and possible.

You may revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our hospital Health Information Management Director/Privacy Officer.

Right to Request Restrictions

  • You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or healthcare operations. You also have the right to request a limit on the health information 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 (1) we not use or disclose information about a surgery you had or (2) that certain people are not to be told of certain information.
  • We are required to agree to your request only if (1) except as otherwise required by law, the disclosure is to your health plan and the purpose is related to payment or healthcare operations (and not treatment purposes), and (2) your information pertains solely to healthcare services for which you have paid in full. For other requests, we are not required to agree. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
  • If you pay for a service or health care item in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will agree unless a law otherwise requires us to share that information. This must be requested prior to the delivery of services, at the point of registration.

How to make a request
To request restrictions or limitations, you must make your request in writing to the Health Information Management Director/Privacy Officer. 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.

Right to a Paper Copy of This Notice
You may obtain a paper copy of the Notice of Privacy Practices for Protected Health Information (“Notice”) by requesting one at our hospital/clinic (in hospital/clinic lobby, Gollier Center Lobby, Emergency Room, or from the Health Information Management/Medical Records Department).

Right to Inspect and Copy Your Records

  • You have the right to inspect and obtain a copy of your health /medical record and billing record. You may exercise this right by delivering your request in writing to the Health Information Management/Medical Records Department in the hospital or to the Business Office at the Gollier Center by using the form we provide to you upon request. Please note that by law we have 30 business days to process your request and may assess a charge not to exceed that allowed by Federal and State Law. If you request this information electronically, we will comply with that request.
  • You have the right to appeal, in writing to the Health Information Management Director/Privacy Officer, a denial of access to your protected heath information except in certain circumstances. These circumstances include the release of psychotherapy notes, information compiled in reasonable anticipation of, or for use in civil, criminal or administrative action or proceeding, information subject to special laws or other information not contained in the medical record/billing records.
  • We may deny your request to inspect and copy in certain very limited circumstances. Certain reasons for the denial are not reviewable and some are reviewable. If you are denied access to health information you will be informed in writing. In certain circumstances you may request that the denial be reviewed. If the original denial of access to the medical records was made by a licensed health care provider as allowed by law, another licensed healthcare professional chosen by the Facility will review your request and denial. You will be advised in writing of the outcome of the review.

We will act upon your request within 30 business days of receipt.

Right to Amend Your Records

  • You have the right to request, in writing, that your health record be amended to correct incomplete or inaccurate information by delivering a written request to our hospital using the form we provide to you upon request. All amendment requests should be directed to the Health Information Management Director/Privacy Officer listed on page 1. Your request may be fulfilled so long as the records are still kept by our facility. You must include in your request the reason for the amendment.
  • Your request for amendment may be denied for the following reasons:
    • Information was not created by our facility, unless the person or entity that created that information is no longer available to make the amendment;
    • Is not part of the health information kept by or for the facility;
    • Is not part of the health information which you should be permitted to inspect and copy;
    • Is accurate and complete.
  • You have the right to file a written statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information (PHI). [The length of this statement is defined in RMH Policy and Procedure for Processing Amendments to Protected Health Information.]

We will act upon your request within 60 business days of receipt.

If you wish to exercise any of the above rights, please contact the Health Information Management Director/Privacy Officer at the contact information list on page 1 of this notice. Please submit your request in writing during normal business hours (8 am to 4:30 pm Monday to Friday). If you are present for a current registration, you may communicate your wishes to the registration staff at that time. Designated staff in these departments will forward your request to Health Information Management Director/Privacy Officer for processing.

Our Responsibilities

The Hospital is Required To:

  • Maintain the privacy of your health information as required by law;
  • Explain our legal duties & privacy practices in connection with your health care records;
  • Provide you with a notice as to our duties and privacy practices as to the information we collect about you (this “Notice”);
  • Abide by the terms of this notice;
  • Notify you if we cannot accommodate a requested restriction or request; and,
  • Accommodate your reasonable requests regarding methods to communicate health information with you.

We reserve the right to amend, change, or eliminate provisions in our privacy and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change; we will amend our Notice”. You are entitled to receive a revised copy of the “Notice” by calling and requesting a copy of our “Notice” or by visiting our hospital and picking up a copy. It is also available on the internet at

Uses and Disclosures of PHI:

Use of Your Health Information for Treatment Purposes

  • We may disclose health information about you to doctors with Facility privileges, nurses, technicians, medical students, and nurse anesthetists or other Facility staff or personnel who are involved in taking care of you at the Facility. Different departments of the Facility also may share health information about you in order to coordinate the different services you need, such as prescriptions, lab work and x-rays. We also may disclose health information about you to people outside the Facility who may be involved in your medical care while you are in the Facility or after you leave the Facility, such as other doctors, health care workers, family members, clergy or others we use to provide services that are part of your care.
  • Appointment Reminders: We may use or disclose health information to contact you, a family member or friend involved in your health care or as authorized by you as a reminder that you have an appointment for treatment or care at our medical facility, unless you tell us not to do so. We may also leave a reminder on your answering machine/voice mail system unless you tell us not to.

Use of Your Health Information for Payment Purposes

We submit a request for payment to your health insurance company. The health insurance company requests information from us regarding medical care given to you. We will provide information to them about you and the care given.

Use of Your Health Information for Health Care Operations
The state licensing authority wants to review records to assure that we have acted consistent with state law regarding your care. In doing so, it wants to take a sampling that includes review of your chart (health/medical record). At the licensing authority’s request, we will provide a copy of your record.

Other Uses and Disclosures
Business Associates
We have business associates with whom we may share your protected health information. For example, in preparing our annual financial statement, auditors may need to review samples of the medical care given at our facility. We may is close your health information to the accounting firm to prepare this material.

Unless you notify us in writing that you object, we will use and disclose your name, location, general condition, and religious affiliation in a hospital directory. This information may be provided to members of the clergy, and except for religious affiliation, to other people who ask for you by name.

Unless you object in writing, we may use or disclose your protected health information to notify, or assist you in notifying, a family member, personal representative, or other person responsible for your care, about your location, your general condition, or your death.

Communications with Family
Using our best judgment, unless you object in writing, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your medical care or in payment for such care if you do not object, OR in an emergency. If you are unable to make your preference known due to your medical condition (for example if you are unconscious) we may share your information if we believe it is in your best interest for medical care.

We may disclose information to researchers when their research has been approved by an institutional review board (IRB) that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

Disaster Relief
We may use and disclose your protected health information to assist in disaster relief efforts.

Funeral Directors/Mortuaries/Coroners
We may disclose your protected health information to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.

Organ Procurement Organizations (ex: Midwest Transplant Network)
Consistent with applicable law, we may disclose your protected health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

We may share information with you about products or services provided by AdventHealth Ottawa which may be of interest to you, but only in face-to-face communications with you and involving items of nominal value. We must inform you if we are receiving payment for our role in marketing.

We, and the AdventHealth Ottawa Foundation, may use information about you such as your name, address, and phone number, insurance status, age and gender and the dates you received services here in order to contact you in the future to raise money for our organization. The money raised through these activities is used to expand and support the healthcare services and educational programs we provide to the community. No information about your health or health care may be used or disclosed for fundraising purposes. If you do not wish to be contacted as part of our fundraising efforts, please notify the Director of Business Development and Marketing, AdventHealth Ottawa/Gollier Center, 1301 S. Main Street, Ottawa, KS, 66067.

Food and Drug Administration (FDA)
We may disclose to the FDA your protected health information relating to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.

Workers Compensation
If you are seeking compensation through Workers’ Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers’ Compensation.

Public Health (Ex: Kansas Tumor Registry; Kansas Department of Health and Environment, Social Services Administration). As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Abuse and Neglect
We may disclose your protected health information to public authorities as allowed by law to report abuse and neglect.

Correctional Institutions
If you are an inmate of a correctional institution, we may disclose to the institution or agents thereof your protected health information necessary for your health and safety of other individuals.

Law Enforcement
We may disclose your protected health information for law enforcement purposes as required by law, when required by a court order, or in cases involving felony prosecutions, or to the extent an individual is in custody of law enforcement.

Health Oversight
Federal Law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities (Ex: Joint Commission for Accreditation of Healthcare Organizations, Kansas Hospital Association).

Judicial/Administrative Proceedings
We may disclose your protected health information in the course of any judicial or administrative proceeding or as allowed or required by law, without your consent, or as directed by a proper court order. To avert a serious threat to health and/or safety, we may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health and/or safety of a person or the public.

For Specialized Government Functions
We may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.

Special Situations: (Sharing of Information only with your written authorization)

  • Marketing: We may only share your information for marketing of Facility Services with your written permission.
  • Sale of Health Information: We may only sell your health information with your written permission.
  • Release of Psychotherapy Notes: We may only release most psychotherapy notes with your written permission.

Other Uses
Other uses and disclosures besides those identified in this notice will be made only as otherwise authorized by law or with your written authorization and you may revoke the authorization as previously provided at any time. To revoke any permission previously provided to us or permission given to us in the future, you must revoke the permission in writing by sending it directly to the Health Information Management Director/Privacy Officer listed on page 1. If you choose to revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any previous disclosures already made with your permission.

To Request Information or File a Complaint
If you have questions, would like additional information, or want to report a problem regarding the handling of your information, or believe your privacy rights have been violated, you may contact:
Judy Hintzman
Health Information Management Director/Privacy Officer
1301 South Main Street
Ottawa, Kansas 66067

You may also file a complaint by the following methods:

We cannot, and will not, require you to waive your right to file a complaint with the Secretary of the U.S.

Department of Health and Human Services (HHS) as a condition of receiving treatment from the hospital.

We cannot, and will not, retaliate against you for filing a complaint with the Secretary of HHS.

To Obtain a Copy of “Notice” when Revised

We maintain a hospital website that provides information about our hospital. This “Notice” is on the website which is located at

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the Facility, and on our website. You will find the date the notice became effective at the top of the first page below the title. In addition, each time you register at or are admitted to the Facility for treatment or healthcare services, as an inpatient or outpatient, a copy of the current notice in effect will be given to you if you request it.

The Organized Health Care Arrangement
This “Notice” applies to all segments of AdventHealth Ottawa and all members of the AdventHealth Organized Health Care Arrangement. The OHCA encompasses all members of the Franklin County medical community who practice at or see patients of AdventHealth Ottawa.

Effective Date of this Notice: November 14, 2014