Notice of Privacy Rights

SALEM TOWNSHIP HOSPITAL
NOTICE OF PRIVACY PRACTICES
Effective: September 23, 2013
Version II

This notice will tell you how we may use and disclose protected health information about you. Protected health information
means any health information about you that identifies you or for which there is a reasonable basis to believe the information
can be used to identify you. In this notice, we call all of that protected health information, Medical information.

This notice also will tell you about your rights and our duties with respect to medical information about you. In addition, it will tell you how to file a complaint with us if you believe we have violated your privacy rights.

Notice of Privacy Practice Sept 23 2013 Version II 8-18

How We May Use and Disclose Medical Information About You

We use and disclose medical information about you for a number of different purposes. Each of those purposes is
described below.

For Treatment
We may use medical information about you to provide, coordinate or manage your health care and related services
by both us and other health care providers. We may disclose medical information about you to doctors, nurses,
hospitals and other health facilities who become involve in your care. We may consult with other health care
providers concerning you and as part of the consultation share your medical information with them. Similarly, we may
refer you to another health care provider and as part of the referral share medical information about you with that
provider. For example, we may conclude you need to receive services from a physician with a particular specialty.
When we refer you to that physician, we also will contact that physician=s office and provide medical information
about you to them so they have information they need to provide services for you.

For Payment
We may use and disclose medical information about you so we can be paid for the services we provide to you. This
can include billing you, your insurance company, or a third party payor. For example, we may need to give your
insurance company, or a collection service company, information about the health care services we provide to you so
the company will pay us, or collect payment on our behalf, for those services or reimburse you for amounts you have
paid. We also may need to provide your insurance company or a government program, such as Medicare or Medicaid,
with information about your medical condition and the health care you need to receive to determine if you are
covered by that insurance or program.

For Health Care Operations
We may use and disclose medical information about you for our own health care operations. These are necessary for
us to operate Salem Township Hospital and to maintain quality health care for our patients. For example, we may
use medical information about you to review the services we provide and the performance of our employees in caring
for you. We may disclose medical information about you to train our staff, volunteers and students working in Salem
Township Hospital. We also may use the information to study ways to more efficiently manage our organization.

How We Will Contact You

Unless you tell us otherwise in writing, we may contact you either by telephone or by mail at either your home or your
workplace. At either location, we may leave messages for you on the answering machine or voice mail. If you want
to request that we communicate to you in a certain way or at a certain location, see ARight to Receive Confidential
Communications@ of this Notice.

Appointment Reminders

We may use and disclose medical information about you to contact you to remind you of an appointment you have
with us.

Treatment Alternatives

We may use and disclose medical information about you to contact you about treatment alternatives that may be of
interest to you.

Health Related Benefits and Services

We may use and disclose medical information about you to contact you about health-related benefits and services
that may be of interest to you.

Salem Township Hospital Directory (Hospital Census)

We may include your name and your location in our facility in our directory while you are a patient in our facility. This
information may be released to people who ask for you by name. Your religious affiliation may be given to members
of the clergy, such as a minister, priest or rabbi. If you do not want your name included in our facility directory, or if
you want to restrict the information we include in the directory, you must notify our Patient Registration Department of
your objection at the time of your registration process.

Individuals Involved in Your Care

We may disclose to a family member, other relative, a close personal friend, or any other person identified by you,
medical information about you that is directly relevant to that person=s involvement with your care or payment related
to your care. We also may use or disclose medical information about you to notify, or assist in notifying, those
persons of your location, general condition, or death. If there is a family member, other relative, or close personal
friend that you do not want us to disclose medical information about you to, please notify our Patient Registration
Department or tell one of our staff members who is providing care to you.

Disaster Relief

We may use or disclose medical information about you to a public or private entity authorized by law or by its charter
to assist in disaster relief efforts. This will be done to coordinate with those entities in notifying a family member,
other relative, close personal friend, or other person identified by you of your location, general condition or death.

Required by Law

We may use or disclose medical information about you when we are required to do so by law.

Public Health Activities

We may disclose medical information about you for public health activities and purposes. This includes reporting
medical information to a public health authority that is authorized by law to collect or receive the information for
purposes of preventing or controlling disease, or one that is authorized to receive reports of child abuse and neglect.
It also includes reporting for purposes of activities related to the quality, safety, or effectiveness of a United States Food and Drug Administration regulated product or activity.

Victims of Abuse, Neglect or Domestic Violence

We may disclose medical information about you to a government authority authorized by law to receive reports of
abuse, neglect, or domestic violence, if we believe you are a victim of abuse, neglect, or domestic violence. This will
occur to the extent the disclosure is: (a) required by law; (b) agreed to by you; or, (c) authorized by law and we
believe the disclosure is necessary to prevent serious harm to you or to other potential victims, or, if you are
incapacitated and certain other conditions are met, a law enforcement or other public official represents that
immediate enforcement activity depends on the disclosure.

Health Oversight Activities

We may disclose medical information about you to a health oversight agency for activities authorized by law, including
audits, investigations, inspections, licensure or disciplinary actions. These and similar types of activities are
necessary for appropriate oversight of the health care system, government benefit programs, and entities subject to
various government regulations.

Judicial and Administrative Proceedings

We may disclose medical information about you in the course of any judicial or administrative proceeding in response
to an order of the court or administrative tribunal. We also may disclose medical information about you in response to
a subpoena, discovery request, or other legal process but only if efforts have been made to tell you about the request
or to obtain an order protecting the information to be disclosed.

Disclosures for Law Enforcement Purposes

We may disclose medical information about you to a law enforcement official for law enforcement purposes:

1. As required by law.
2. In response to a court, grand jury or administrative order, warrant or subpoena.
3. To identify or locate a suspect, fugitive, material witness or missing person.
4. About an actual or suspected victim of a crime and that person agrees to the disclosure. If we are unable to
   obtain that person=s agreement, in limited circumstances, the information may still be disclosed.
5. To alert law enforcement officials to a death if we suspect the death may have resulted from criminal
   conduct.
6. About crimes that occur at our facility.
7. To report a crime in emergency circumstances.

Coroners and Medical Examiners

We may disclose medical information about you to a coroner or medical examiner for purposes such as identifying a
deceased person and determining cause of death.

Funeral Directors

We may disclose medical information about you to funeral directors as necessary for them to carry out their duties.
Organ, Eye or Tissue Donation

To facilitate organ, eye or tissue donation and transplantation, we may disclose medical information about you to
organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs,
eyes or tissue.

To Avert Serious Threat to Health or Safety

We may use or disclose protected health information about you if we believe the use or disclosure is necessary to
prevent or lessen a serious or imminent threat to the health or safety of a person or the public. We also may release
information about you if we believe the disclosure is necessary for law enforcement authorities to identify or
apprehend an individual who admitted participation in a violent crime or who is an escapee from a correctional
institution or from lawful custody.

Military

If you are a member of the Armed Forces, we may use and disclose medical information about you for activities
deemed necessary by the appropriate military command authorities to assure the proper execution of the military
mission. We may also release information about foreign military personnel to the appropriate foreign military authority
for the same purposes.

National Security and Intelligence

We may disclose medical information about you to authorized federal officials for the conduct of intelligence, counterintelligence,
and other national security activities authorized by law.

Protective Services for the President

We may disclose medical information about you to authorized federal officials so they can provide protection to the
President of the United States, certain other federal officials, or foreign heads of state.

Inmates; Persons in Custody

We may disclose medical information about an inmate or other individual to a correctional institution or law
enforcement official having custody of the inmate or other individual. The disclosure will be made if the disclosure is
necessary: (a) to provide health care to such individuals; (b) for the health and safety of such individual or other
inmates; (c) the health and safety of the officers or employees of or others at the correctional institution; (d) the health
and safety of such individuals and officers or other persons responsible for the transporting of inmates or their transfer
from one institution, facility, or setting to another; (e) law enforcement on the premises of the correctional institution;
or, (f) the administration and maintenance of the safety, security, and good order of the correctional institution.

Workers Compensation

We may disclose medical information about you to the extent necessary to comply with workers= compensation and
similar laws that provide benefits for work-related injuries or illness without regard to fault.

Certain Uses and Disclosures that Require Your Written Authorization

Psychotherapy Notes

Your authorization is required before we may use or disclose psychotherapy notes unless the use or disclosure is: (a)
by the originator of the psychotherapy notes for treatment; (b) for our own training programs for students, trainees, or
practitioners in mental health; (c) to defend ourselves in a legal action or other proceeding brought by you; (d) when
required by law; or, (e) permitted by law for oversight of the originator of the psychotherapy notes.

Marketing

We may use and disclose medical information about you to communicate with you about a product or service to
encourage you to purchase the product or service. Generally, this may occur without your authorization. However,
your authorization is required if: (a) the communication is to provide refill reminders or otherwise communicate about
a drug or biologic that is, at the time, being prescribed for you and we receive any financial remuneration in exchange
for making the communication which is not reasonably related to our cost in making the communication; or, (b) except
as stated in (a), we use or disclose your medical information for marketing purposes and we receive direct or indirect
financial remuneration from a third party for doing so. When an authorization is required to communicate with you
about a product or service to encourage you to purchase the product or service, the authorization will state that
financial remuneration to Salem Township Hospital is involved.

Sale of Information

Your authorization is required for any disclosure of your medical information when the disclosure is in exchange for
direct or indirect remuneration from or on behalf of the recipient of the medical information. However, your
authorization may not be required under certain conditions if the disclosure is: (a) for public health purposes; (b) for
research purposes; (c) for treatment and payment; (d) if we are being sold, transferred, merged or consolidated; (e) to
a business associate of ours for activities undertaken on our behalf; (f) to you when requested by you; (g) required by
law; (h) when permitted by applicable law where the only remuneration received by us is a fee permitted by law.

Other Uses and Disclosures

Other uses and disclosures will be made only with your written authorization. You may revoke such an authorization
at any time by notifying the HIPAA Privacy Officer at Salem Township Hospital in writing of your desire to revoke it.
However, if you revoke such an authorization, it will not have any affect on actions taken by us in reliance on it.

Your Rights With Respect to Medical Information About You

You have the following rights with respect to medical information that we maintain about you.

Right to Request Restrictions

You have the right to request that we restrict the uses or disclosures of medical information about you to carry out
treatment, payment, or health care operations. You also have the right to request that we restrict the uses or
disclosures we make to: (a) a family member, other relative, a close personal friend or any other person identified by
you; or, (b) public or private entities for disaster relief efforts. For example, you could ask that we not disclose
medical information about you to your brother or sister.

To request a restriction, you may do so at any time. If you request a restriction, you must submit it in writing to the
HIPAA Privacy Officer at Salem Township Hospital, 1201 Ricker Drive, Salem, IL. 62881, and tell us: (a) what
information you want to limit; (b) whether you want to limit use or disclosure or both; and, (c) to whom you want the
limits to apply (for example, disclosures to your spouse).

With one exception, we are not required to agree to any requested restriction. The exception is that we will always
agree to a request to restrict disclosures to a health plan if (a) the disclosure is for the purpose of carrying out
payment or health care operations and is not otherwise required by law; and, (b) the information relates solely to a
health care item or service for which you, or someone on your behalf (other than the health plan) has paid us in full.
If we do agree to a restriction, we will follow that restriction unless the information is needed to provide emergency
treatment. Even if we agree to a restriction, either you or Salem Township Hospital can later terminate the restriction.

Right to Receive Confidential Communications

You have the right to request that we communicate medical information about you to you in a certain way or at a
certain location. For example, you can ask that we only contact you by mail or at work. We will not require you to tell
us why you are asking for the confidential communication.

If you want to request confidential communication, you must submit it in writing to the HIPAA Privacy Officer at Salem
Township Hospital, 1201 Ricker Drive, Salem, IL. 62881. Your request must state how or where you can be
contacted.

We will accommodate reasonable requests. However, we may, when appropriate, require information from you
concerning how payment will be handled. We also may require an alternate address or other method to contact you.

Right to Inspect and Copy

With a few very limited exceptions, such as psychotherapy notes created by a clinical psychologist or a clinical social
worker, you have the right to inspect and obtain a copy of medical information about you.

To inspect or copy medical information about you, you must submit your request in writing to the HIPAA Privacy
Officer at Salem Township Hospital, 1201 Ricker Drive, Salem, IL. 62881. Your request should state specifically what
medical information you want to inspect or copy. Your request should state the form of access and copy you desire,
such as I paper or in electronic media. If you request a copy of the information, we may charge a fee for the costs of
copying and, if you ask that it be mailed to you, the cost of mailing.

We usually will act on your request within thirty (30) calendar days after we receive your request. If we grant your
request, in whole or in part, we will inform you of our acceptance of your request and provide access and copies.

We may deny your request to inspect and copy medical information if the medical information involved is:

A. Psychotherapy notes created by a clinical psychologist or clinical social worker;

B. Information compiled in anticipation of, or use in, a civil, criminal or administrative action or proceeding;
If we deny your request, we will inform you of the basis for the denial, how you may have our denial reviewed, and
how you may file a complaint. If you request a review of our denial, it will be conducted by a licensed health care
professional designated by us who was not directly involved in the denial. We will comply with the outcome of that
review.

Right to Amend

You have the right to ask us to amend medical information about you. You have this right for so long as the medical
information is maintained by us.

To request an amendment, you must submit your request in writing to the HIPAA Privacy Officer at Salem Township
Hospital, 1201 Ricker Drive, Salem, IL. 62881. Your request must state the amendment desired and provide a
reason in support of that amendment.

We will act on your request within sixty (60) calendar days after we receive your request. If we grant your request, in
whole or in part, we will inform you of our acceptance of your request and provide access and copying.

If we grant the request, in whole or in part, we will seek your identification of and agreement to share the amendment
with relevant other persons. We also will make the appropriate amendment to the medical information by appending
or otherwise providing a link to the amendment.

We may deny your request to amend medical information about you. We may deny your request if it is not in writing
and does not provide a reason in support of the amendment. In addition, we may deny your request to amend
medical information if we determine that the information:

1. Was not created by us, unless the person or entity that created the information is no longer available to act
   on the requested amendment;
2. Is not part of the medical information maintained by us;
3. Would not be available for you to inspect or copy; or,
4. Is accurate and complete.

If we deny your request, we will inform you of the basis for the denial. You will have the right to submit a statement of
disagreement with our denial. Your statement may not exceed three (03) pages. We may prepare a rebuttal to that
statement. Your request for amendment, our denial of the request, your statement of disagreement, if any, and our
rebuttal, if any, will then be appended to the medical information involved or otherwise linked to it. All of that will then
be included with any subsequent disclosure of the information, or, at our election, we may include a summary of any
of that information.

If you do not submit a statement of disagreement, you may ask that we include your request for amendment and our
denial with any future disclosures of the information. We will include your request for amendment and our denial (or a
summary of that information) with any subsequent disclosure of the medical information involved.
You also will have the right to file a complaint about our denial of your request.

Right to an Accounting of Disclosures

You have the right to receive an accounting of disclosures of medical information about you. The accounting may be
for up to six (6) years prior to the date on which you request the accounting but not before April 14, 2003.
Certain types of disclosures are not included in such an accounting:

1. Disclosures to carry out treatment, payment and health care operations;
2. Disclosures of your medical information made to you;
3. Disclosures that are incident to another use or disclosure;
4. Disclosures that you have authorized;
5. Disclosures for our facility directory or to persons involved in your care;
6. Disclosures for disaster relief purposes;
7. Disclosures for national security or intelligence purposes;
8. Disclosures to correctional institutions or law enforcement officials having custody of you;
9. Disclosures that are part of a limited data set for purposes of research, public health, or health care
   operations (a limited data set is where things that would directly identify you have been removed).
10. Disclosures made prior to April 14, 2003.

Under certain circumstances your right to an accounting of disclosures to a law enforcement official or a health
oversight agency may be suspended. Should you request an accounting during the period of time your right is
suspended, the accounting would not include the disclosure or disclosures to a law enforcement official or to a health
oversight agency.

To request an accounting of disclosures, you must submit your request in writing to the HIPAA Privacy Officer at
Salem Township Hospital, 1201 Ricker Drive, Salem, IL. 62881. Your request must state a time period for the
disclosures. It may not be longer than six (6) years from the date we receive your request and may not include dates
before April 14, 2003.

Usually we will act on your request within sixty (60) calendar days after we receive your request. Within that time, we
will either provide the accounting of disclosures to you or give you a written statement of when we will provide the
accounting and why the delay is necessary.

There is no charge for the first accounting we provide to you in any twelve (12) month period. For additional
accountings, we may charge you for the cost of providing the list. If there will be a charge, we will notify you of the
cost involved and give you an opportunity to withdraw or modify your request to avoid or reduce the fee.

Right to Copy of this Notice

You have the right to obtain a paper copy of our Notice of Privacy Practices. You may obtain a paper copy even
though you agreed to receive the notice electronically. You may request a copy of our Notice of Privacy Practices at
any time.

To obtain a paper copy of this notice, contact the HPAA Privacy Officer at Salem Township Hospital, 1201 Ricker
Drive, Salem, IL. 62881. You may also obtain a copy of our Notice of Privacy Practices over the Internet at our web
site, www. sthcares.org.

Our Duties

Generally

We are required by law to maintain the privacy of medical information about you, to provide individuals with notice of
our legal duties and privacy practices with respect to medical information, and to notify affected individuals following a
breach of unsecured protected health information.

We are required to abide by the terms of our Notice of Privacy Practices in effect at the time.

Our Right to Change Notice of Privacy Practices

We reserve the right to change this Notice of Privacy Practices. We reserve the right to make the new notice=s
provisions effective for all medical information that we maintain, including that created or received by us prior to the
effective date of the new notice.

Availability of Notice of Privacy Practices

A copy of our current Notice of Privacy Practices will be posted on the Communication wall located at our Patient
Access Department.

At any time, you may obtain a copy of the current Notice of Privacy Practices by contacting the HIPAA Privacy Officer
at Salem Township Hospital, 1201 Ricker Drive, Salem, IL. 62881, 618-548-3194, ext. 8222.

Effective Date of Notice

The effective date and version of the notice will be stated on the first page of the notice.

Complaints

You may file a complaint with us and to the United States Secretary of Health and Human Services if you believe your
privacy rights have been violated by us.

To file a complaint with us, contact the HIPAA Privacy Officer at Salem Township Hospital, 1201 Ricker Drive, Salem,
IL. 62881. All complaints should be submitted in writing.

To file a complaint with the United States Secretary of Health and Human Services, send your complaint in care of:
Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington,
D.C. 20201. Complaints may also be filed online. Go to: http://www.hhs.gov.ocr.
You will not be retaliated against for filing a complaint.

Questions and Information

If you have any questions or want more information concerning this Notice of Privacy Practices, please contact the
HIPAA Privacy Officer at Salem Township Hospital, 1201 Ricker Drive, Salem, IL. 62881, 618-548-3194, ext. 8222.