Black Hills Surgical Hospital | 216 Anamaria Drive | Rapid City, South Dakota 57701
Phone: (605) 721-4700 | Toll Free: 1 (800) 818-1890 | Fax: (605) 721-4708

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.

• Our Privacy Commitment
• How We Use & Disclose Your Health Information
• Other Uses and Disclosures
• Your Individual Rights
• Our Privacy Duties
• Who Follows this Notice
• Questions and Complaints

Effective Date: April 14, 2003

Our Privacy Commitment

The protection of the privacy of your health information is important to us at Black Hills Surgical Hospital. In addition, we are required by law to maintain the confidentiality of your health information and provide you with this notice of our privacy practices. In this notice we describe the ways that we may use and disclose health information about you.

How We Use & Disclose Your Health Information

We are permitted to use and disclose your health information for treatment, payment, and health care operations. Following is a description and examples of how we use your health information for those purposes.

Treatment: Your health information may be used to evaluate your health, diagnose medical conditions, and provide quality care. The information in your medical record, such as laboratory tests, X-rays or prescriptions, will be available to other health professionals who may provide treatment or who may be consulted by our staff members.

Payment: Your health information may be used by us and other health care professionals involved in your treatment to obtain payment from you, your insurance company, and other sources of coverage or payment. For example, we may contact your insurance company to verify benefits or to notify them of services to be provided that may require preauthorization.

Health Care Operations: We use health information to evaluate and promote the quality of care and service provided to you and to support regular business activities. For example, we may use health information for evaluating the performance of staff, business planning, and financial management of our company.

Other Uses and Disclosures

We may also use your health information to:

• Remind you of an appointment and obtain information via pre-operative telephone calls.

• Send you newsletters or announcements containing information you may find interesting about us or with regard to treatment and management of your medical condition.

• Disclose information to family or other representatives involved in your care or payment for your care, provided you do not object.

• Include you in our patient directory for callers, visitors, and clergy, unless you notify us of any restrictions or limitations.
  

There are also certain special circumstances in which we may use or disclose your health information without your authorization as follows:

• For public health reporting purposes such as reporting communicable and other diseases and injuries permitted by law, victims of abuse or neglect, or work-related illnesses.

• To law enforcement agencies to support government audits and inspections to facilitate investigations, health oversight activities, or to comply with government-mandated reporting.

• For lawsuits and similar proceedings.

• To medical examiners, coroners, and funeral directors.

• For organ and tissue donations.

• For research in certain limited circumstances approved under federal rules.

• To avert a serious threat to health or safety.

• For specialized government functions such as national security and intelligence activities.

• For workers’ compensation or other similar programs for work-related injuries or illness.

Your Individual Rights

You have certain rights under federal privacy standards. You have the right to:

• Request restrictions on the use and disclosure of your protected health information. We may not be required to agree with your request.

• Receive confidential communication concerning your medical condition and treatment. For example, you may request we contact you only at a specific phone number or address.

• Inspect and copy your protected health information. For limited reasons as allowed by law, we may deny your access to specific information; however, you may request a review of our denial. As permitted by federal regulation, we require the requests be submitted in writing. You may contact us to obtain a form to request this access. Reasonable fees may apply.

• Request to amend or submit corrections to your health information, provided the request is in writing and you give us the reason for the request. We may deny your request in certain circumstances, such as when we believe the information is already accurate and complete.

• Receive an accounting of certain disclosures of your health information during a specified period of up to six years, excluding dates prior to April 14, 2003. The accounting does not include disclosures made for treatment, payment, health care operations, disclosures required by law and other disclosures as referenced in this notice. The first request in a 12-month period is free, but we may charge you for our reasonable costs for additional requests in the same 12-month period.

• Receive a paper copy of this notice even if you previously agreed to receive it electronically.

Our Privacy Duties

Federal regulations require that we protect the privacy of health information that identifies a patient, or where there is reasonable basis to believe the information can be used to identify a patient. We also are required to abide by the terms of our Notice of Privacy Practices that is currently in effect. As permitted by law, we reserve the right to amend or modify our privacy practices. These changes may be a result of changes in federal or state laws and regulations. Current notices will be posted in our facilities and on our website, www.bhsc.com. Upon request, we will provide you with a copy of the notice.

Use or disclosure of your health information for purposes other than as described in our notice will require your written authorization. You may revoke your authorization at any time, provided it is in writing. However, your decision to revoke the authorization will not affect any use or disclosure of information that occurred before you notified us of your decision to revoke your authorization.

Who Follows this Notice

This notice describes the privacy practices of Black Hills Surgical Hospital and Black Hills Imaging Center, as well as members of an organized health care arrangement performing services in our facilities, unless they provide you with a formal notice of their privacy practices. Members of the organized health care arrangement covered by this notice may include anesthesiologists, hospitalists, radiologists, pharmacists and physical therapists. These health care providers are not employed by us but are either authorized to provide services to patients in our facilities or have a contractual relationship with us.

Questions and Complaints

If you would like further information concerning our privacy practices or believe your privacy rights have been violated, you should contact us using the following address or telephone number:

Privacy Official
Black Hills Surgical Hospital, LLP
1868 Lombardy Drive
Rapid City, SD 57703
Telephone: 605-721-4900
Toll Free: 1-800-596-4519

You will not be penalized or otherwise retaliated against for filing a complaint. You may also file a complaint with the Secretary of the Department of Health and Human Services.