I.          Who Presents this Notice

            This Notice describes the privacy practices of Tenet Health System SL, Inc, which does business as Saint Louis University Hospital ("Hospital"), including members of the Hospital’s workforce, employees and volunteers and Saint Louis University ("University"), including University’s faculty physicians, allied health professionals and students (the Hospital, University and the individual health care providers together are sometimes called "the Hospital, University and Health Professionals" in this Notice).  While the Hospital, University and Health Professionals engage in many joint activities and provide clinically integrated care, the Hospital, University and Health Professionals each are separate legal entities.  This Notice applies to services furnished to you at the Hospital as a Hospital inpatient or outpatient or any other services provided to you in a Hospital-affiliated program involving the use or disclosure of your health information.

II.                  Privacy Obligations

The Hospital, University and Health Professionals each are required by law to maintain the privacy of your health information maintained by the Hospital ("Hospital Protected Health Information" or " Hospital PHI”) and to provide you with this Notice of legal duties and privacy practices with respect to your Hospital PHI.  When the Hospital, University and Health Professionals use or disclose Hospital PHI, the Hospital, University and Health Professionals are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).  Special privacy obligations, described in Section IV.D, apply to you if you are admitted to the Hospital’s psychiatric unit or chemical dependency treatment center.

 III.            Permissible Uses and Disclosures Without Your Written Authorization

In certain situations, which are described in Section IV below, your written authorization must be obtained in order to use and/or disclose your Hospital PHI.  However, your authorization is not required for the following uses and disclosures unless a law protecting "Highly Confidential Information" (defined in Section IV.C below) requires an authorization:

A.            Uses and Disclosures For Treatment, Payment and Health Care Operations.  Your Hospital PHI, but not your “Highly Confidential Information” (defined in Section IV.C below), may be used and disclosed in order to treat you, obtain payment for services provided to you and conduct “health care operations” as detailed below:

·           Treatment.  Your Hospital PHI may be used and disclosed to provide treatment and other services to you--for example, to diagnose and treat your injury or illness.  In addition, you may be contacted to provide you appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.  Your Hospital PHI also may be disclosed to other providers involved in your treatment.

·           Payment.  Your Hospital PHI may be used and disclosed to obtain payment for services provided to you--for example, disclosures to claim and obtain payment from your health insurer, HMO, or other company that arranges or pays the cost of some or all of your health care ("Your Payor") to verify that Your Payor will pay for health care.  Your Hospital PHI also may be disclosed to other providers for them to obtain payment.

·              Health Care Operations.  Your Hospital PHI may be used and disclosed for health care operations, and may be shared between the Hospital, University and Health Professionals for certain health care activities, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care delivered to you.  For example, Hospital PHI may be used to evaluate the quality and competence of physicians, nurses and other health care workers, or to train students, residents and fellows.  Hospital PHI may be disclosed to the Hospital Privacy Officer in order to resolve any complaints you may have and ensure that you have a comfortable visit.

Your Hospital PHI also may be disclosed to your other health care providers when such Hospital PHI is required for them to treat you, receive payment for services they render to you, or conduct certain health care operations, such as quality assessment and improvement activities, reviewing the quality and competence of health care professionals, or for health care fraud and abuse detection or compliance.  In addition, Your Hospital PHI may be shared with business associates who perform treatment, payment and healthcare operations services on behalf of the Hospital, University and Health Professionals.

      B.      Use or Disclosure for Directory of Individuals in Hospital.  Hospital may include your name, location in the Hospital, general health condition and religious affiliation in a patient directory without obtaining your authorization unless you object to inclusion in the directory or are located in a specific ward, wing or unit the identification of which would reveal that you are receiving treatment for HIV/AIDS, substance abuse, or certain other sensitive conditions.  Information in the directory may be disclosed to anyone who asks for you by name or members of the clergy; provided, however, that your religious affiliation will only be disclosed to members of the clergy.

     C.        Disclosure to Relatives, Close Friends and Other Caregivers.  Your Hospital PHI may be used or disclosed (other than your Highly Confidential Information defined in Section IV.C. below) to a family member, other relative, a close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if (1) your agreement is obtained; (2) you do not object to the disclosure after being provided an opportunity to object; or (3) it can be reasonably inferred that you do not object to the disclosure. 

If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, the Hospital, University and/or Health Professionals may exercise professional judgment to determine whether a disclosure is in your best interests.  If information is disclosed to a family member, other relative or a close personal friend, the Hospital, University and/or Health Professionals would disclose only information believed to be directly relevant to the person’s involvement with your health care or payment related to your health care.  Your Hospital PHI also may be disclosed in order to notify (or assist in notifying) such persons of your location or general condition.

D.            Fundraising Communications.  Hospital will not use your Hospital PHI for fundraising.  University may use basic information about you (name, address, dates of service and the like) to contact you to raise funds for University.  You are under no obligation to respond to such communications and if you are contacted by University for fundraising purposes, you will be given the opportunity by University to opt out of receiving future fundraising communications.    

E.             Public Health Activities.  Your Hospital PHI may be disclosed for the following public health activities:  (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports; (3) to report information about products and services under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.

F.   Victims of Abuse, Neglect or Domestic Violence.  Your Hospital PHI may be disclosed to a governmental authority, including the Missouri Department of Social Services or other social service or protective services agency, authorized by law to receive reports of such abuse or need for protective services if there is a reasonable belief that you are elderly or handicapped and a victim of abuse or have a need for protective services. 

G.     Health Oversight Activities.  Your Hospital PHI may be disclosed to a health oversight agency that oversees the health care system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.

H.            Judicial and Administrative Proceedings.  Your Hospital PHI may be disclosed in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.

I.            Law Enforcement Officials.  Your Hospital PHI may be disclosed to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena. 

J.            Deceased Patients.  Your Hospital PHI may be disclosed to a coroner or medical examiner as authorized by law.

K.            Organ and Tissue Procurement.  Your Hospital PHI may be disclosed to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.

L.                  Research.  Your Hospital PHI may be used or disclosed without your consent or authorization if an Institutional Review Board approves a waiver of authorization for disclosure, or to researchers preparing a research protocol.

           M.          Limited Data Set.  The Hospital, University and/or Health Professionals may provide limited health information about you (not including your name, address or other direct identifiers) for research, public health or health care operations, but only if the recipient of such information signs an agreement to protect the information and not use it to identify you.

N.            Health or Safety.  Your Hospital PHI may be used or disclosed to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety.

O.           Specialized Government Functions.  Your Hospital PHI may be disclosed to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.

P.            Workers’ Compensation.  Your Hospital PHI may be disclosed as authorized by and to the extent necessary to comply with Missouri law relating to workers' compensation or other similar programs.

Q.            As Required by Law.  Your Hospital PHI may be used and disclosed when required to do so by any other law not already referred to in the preceding categories.

IV.       Uses and Disclosures Requiring Your Written Authorization

           A.       Use or Disclosure with Your Authorization.  For any purpose other than the ones described above in Section III, your Hospital PHI may be used or disclosed only when you provide your written authorization on an authorization form ("Your Authorization") acceptable to the Hospital.  For instance, you will need to execute an authorization form before Hospital can send your Hospital PHI to your life insurance company or to the attorney representing the other party in litigation in which you are involved. 

B.                 Marketing.  Hospital will obtain your written authorization (“Your Marketing Authorization”) prior to using your Hospital PHI to send you any marketing materials.  (However, marketing materials can be provided to you in a face-to-face encounter without obtaining Your Marketing Authorization.  The Hospital, University and/or Health Professionals are also permitted to give you a promotional gift of nominal value, if they so choose, without obtaining Your Marketing Authorization.)  In addition, Hospital, University and/or Health Professionals may communicate with you about products or services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers or care settings without Your Marketing Authorization.

C.            Uses and Disclosures of Your Highly Confidential Information.  In addition, federal and state law requires special privacy protections for certain highly confidential information about you (“Highly Confidential Information”), including the subset of your Hospital PHI that:  (1) is maintained in psychotherapy notes; (2) is about mental health treatment; (3) is about alcohol and drug abuse prevention, treatment, and referral; (4) is about HIV/AIDS testing or treatment (5) is a report to a public health authority about a communicable disease(s) (6) is a report to a cancer registry; or (7) is about genetic testing, (8) is a report to the state authorities on abortion procedures.  In order for your Highly Confidential Information to be disclosed for a purpose other than those permitted by law, your written Authorization must be obtained.

            D.            Use and Disclosure of Information Upon Admission to a Psychiatric Unit or Alcohol or Drug Abuse Treatment Program.  Information regarding your care in the Hospital’s psychiatric unit or alcohol or drug abuse treatment unit is subject to special protection under state and federal law.  The terms of this Notice shall apply to your Hospital PHI unless otherwise described in this Section IV.D.

·        Psychiatric Treatment.  Your Hospital PHI will be disclosed to Hospital personnel involved in your treatment or supervising those involved in your treatment for the purpose of treating you or consulting about your treatment.  Your Authorization will be obtained prior to disclosing your Hospital PHI to other treatment providers except in the event of a medical emergency or as permitted by law to other persons or agencies responsible for providing health care services to you.  Your Authorization generally will be obtained prior to disclosing your Hospital PHI to obtain payment for services rendered to you, such as for example, to your insurance company.  However, your Hospital PHI may be disclosed to your insurance company or other third party payor to the extent necessary for to make a claim on your behalf for aid or insurance benefits.  On occasion, your Hospital PHI may be used for health care operations but, to the extent possible, your personally identifiable information will be removed.  Neither the Hospital, University or Health Professionals will respond to inquiries about your treatment or disclose information revealing that you are a patient of the psychiatric unit to unauthorized individuals who call the Hospital to seek information.  Your Hospital PHI will not be disclosed to a family member, relative or any other person seeking information about your care unless your written Authorization is obtained.  If you are a minor or have a personal representative (such as a guardian or person authorized under a power of attorney), you will be consulted prior to sharing information with such person.  If you refuse to grant permission or are unable to grant permission, information may be shared with your personal representative only to the extent permitted or required by state law.  The Hospital, University and Health Professionals will comply with state law in reporting your Hospital PHI for public health activities or health oversight activities.  If you disclose information related to child abuse or other types of actual or threatened abuse, the Hospital, University and/or Health Professionals may be required to report such information to governmental authorities responsible to investigate such abuse.  If you commit a crime on the premises, your Hospital PHI may be used to report the crime.  To the extent possible, the Hospital, University and/or Health Professionals will notify you or seek a protective order prior to disclosing information to a judicial or administrative proceeding.  Your Hospital PHI will not be used for marketing.

·        Alcohol or Drug Abuse Treatment.  If you are a recipient of alcohol or drug abuse treatment, your Hospital PHI is protected by federal and state confidentiality laws (42 U.S.C. 290dd-3, 290ee-3 and 42 CFR Part 2).  Violations of these laws is a crime and may be reported to appropriate authorities.  Your Hospital PHI will be disclosed to Hospital personnel within the alcohol or drug abuse treatment program and certain organizations providing services to the program that have a need to know your Hospital PHI to perform their job duties or to medical personnel in the event of a medical emergency.  Your Authorization will be obtained prior to disclosing any Hospital PHI to obtain payment for services rendered to you, such as for example, to your insurance company.  On occasion, your Hospital PHI may be used for health care operations but your identifying information will be removed.  The Hospital, University and Health Professionals will not respond to inquiries about your treatment and will not disclose information revealing that you are a patient of the alcohol or drug abuse treatment program to unauthorized individuals who call the Hospital to seek information.  Your Hospital PHI will not be disclosed to a family member, relative or any other person seeking information about your care unless your written Authorization is obtained.  If you are a minor or have a personal representative (such as a guardian or person authorized under a power of attorney), you will be consulted prior to sharing information with such person.  If you refuse to grant permission or are unable to grant permission, information may be shared with your personal representative only to the extent permitted or required by state law.  The Hospital, University and Health Professionals will comply with federal and state law in reporting your Hospital PHI for public health activities or health oversight activities.  If you disclose information related to child abuse, the Hospital, University and/or Health Professionals may be required to report such information to governmental authorities responsible to investigate such abuse.  If you commit a crime on the premises, your Hospital PHI may be used to report the crime.  To the extent possible, the Hospital, University and/or Health Professionals will notify you or seek a protective order prior to disclosing information to a judicial or administrative proceeding.  Your Hospital PHI will not be used for marketing.

V.        Your Rights Regarding Your Protected Health Information

A.            For Further Information; Complaints.  If you desire further information about your privacy rights, are concerned that your privacy rights have been violated or disagree with a decision made about access to your Hospital PHI, you may contact the Hospital Privacy Office.  You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services.  Upon request, the Privacy Office will provide you with the correct address for the Director.  The Hospital, University and Health Professionals will not retaliate against you if you file a complaint with the Hospital Privacy Office or the Director. 

B.            Right to Request Additional Restrictions.  You may request restrictions on the use and disclosure of your Hospital PHI (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition.  While  all requests for additional restrictions will be carefully considered, the Hospital, University and Health Professionals are not required to agree to a requested restriction.  If you wish to request additional restrictions, please obtain a request form from the Hospital Privacy Office and submit the completed form to the Hospital Privacy Office.  The Hospital will send you a written response.

C.            Right to Receive Confidential Communications.  You may request, and the Hospital, University and Health Professionals will accommodate, any reasonable written request for you to receive your Hospital PHI by alternative means of communication or at alternative locations. 

D.            Right to Revoke Your Authorization.  You may revoke Your Authorization, Your Marketing Authorization or any written authorization obtained in connection with your Highly Confidential Information, except to the extent that the Hospital, University and/or Health Professionals have taken action in reliance upon it, by delivering a written revocation statement to the Hospital Privacy Office identified below.  (A form of Written Revocation is available upon request from the Hospital Privacy Office.)

E.            Right to Inspect and Copy Your Health Information.  You may request access to your medical record file and billing records maintained by Hospital in order to inspect and request copies of the records.  Under limited circumstances, Hospital may deny you access to a portion of your records.  If you are a parent or legal guardian of a minor, certain portions of the minor’s medical record may not be accessible to you (for example records relating to treatment for pregnancy, venereal disease or drug or substance abuse).  If you desire access to your records, please obtain a record request form from the Hospital HIM Department or the Hospital Privacy Office and submit the completed form.  If you request copies of paper records, you will be charged in accordance with federal and state law. To the extent the request for records includes portions of records which are not in paper form (e.g., x-ray films), you will be charged the reasonable cost of the copies.  You also will be charged for the postage costs, if you request that the copies be mailed to you.  

F.            Right to Amend Your Records.  You have the right to request amendment to the Hospital PHI maintained by Hospital in your Hospital medical record file or billing records.  If you desire to amend your records, please obtain an amendment request form from the Hospital Privacy Office and submit the completed form.  Your request will be accommodated unless the Hospital, University and/or Health Professionals believe that the information that would be amended is accurate and complete or other special circumstances apply.

G.                Right to Receive an Accounting of Disclosures.  Upon request of the Hospital, you may obtain an accounting of certain disclosures of your Hospital PHI made during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003.  If you request an accounting more than once during a twelve (12) month period, you will be charged a reasonable cost-based fee not to exceed 37 cents for each page

H.            Right to Receive Paper Copy of this Notice.  Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically. 

VI.            Effective Date and Duration of This Notice

A.            Effective Date.  This Notice is effective on December 8, 2003.

B.            Right to Change Terms of this Notice.  The terms of this Notice may be changed at any time.  If this Notice is changed, the new notice terms may be made effective for all Hospital PHI, including any information created or received prior to issuing the new notice.  If this Notice is changed, the Hospital will post the new notice in its waiting areas and on the Hospital's Internet site at www.sluhospital.com.  You also may obtain any new notice by contacting the Hospital Privacy Office.

VII.            Privacy Office

You may contact the Hospital Privacy Office at:

Saint Louis University Privacy Office

3635 Vista Ave at Grand Blvd.

St. Louis, MO 63110 -0250

Phone: 314-268-5580

Fax: 314-268-5768

email address: SLUHprivacy.office@tenethealth.com

OR

Corporate Privacy Office

Tenet HealthCare

13737 Noel Road, Suite 100

Dallas, TX  75240

E-mail:  PrivacySecurityOffice@tenethealth.com

                        Ethics Action Line (EAL)  1-800-8-ETHICS