NOTICE OF PRIVACY PRACTICES 

For Union Hospital, Inc. d/b/a/ Union Hospital Terre Haute and d/b/a Union Hospital Clinton and Union Associated Physicians Clinic, LLC d/b/a/ Union Medical Group patients 

Effective Date of this Notice: April 14, 2003 
Revised Date of this Notice: September 23, 2013 
Revised Date of this Notice: August 2, 2016 
Revised Date of this Notice: November 11, 2021 
 

If you have any questions about this Notice, please call the Compliance Department at 812.238.7533. 

Union Hospital, Inc. 
d/b/a Union Hospital Terre Haute 
1606 N. 7th Street 
Terre Haute, IN 47804 
 

Union Hospital, Inc. 
d/b/a Union Hospital Clinton 
801 S. Main Street 
Clinton, IN 47842 
 

Union Associated Physicians Clinic, LLC 
d/b/a Union Medical Group 
221 S. 6th Street 
Terre Haute, IN 47807 
 

www.union.health 

 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY. 
 

How We May Use and Disclose Your Medical Information 

The following categories describe different ways that we use and disclose medical information. Information may be disclosed in writing, orally or electronically. Not every use or disclosure in each category will be listed; however, all the ways we are permitted to use and disclose information fall within one of the categories. Other uses and disclosures not described in this Notice will be made only with the authorization from the individual patient or qualified patient representative. 
 

Our Pledge Regarding Medical Information 

We understand that medical information about you and your health is personal. We are committed to protecting your privacy. We create a record of the care and services you receive at our facilities listed above. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all records of your care generated by the facilities listed above, whether in paper or electronic form. 
 

We are required by law to: 

• Make sure that medical information that identifies you is kept private; 

• Give you this notice of our legal duties and privacy practices; 

• Follow the terms of this Notice currently in effect; and 

• Notify you in the event of a breach of your unsecured protected health information (“PHI”). 

The rights listed in this Notice will not apply to inmates of a correctional institution. 

We will collect only the personal information that is necessary to conduct our business, i.e., only the information necessary to provide quality health care and accurately bill you or your insurance carrier. 
 

Who has access to your information? 

We restrict access to your personal information to only those persons with a need to know. We maintain physical, electronic, and procedural safeguards that meet state and federal regulations to guard your personal medical information. We will not use or disclose your PHI without your authorization, except as otherwise described in this Notice. 
 

How we may use and disclose your information 

1. For Treatment: 

We may use or disclose your medical information to provide you with quality treatment or services. Your information may be accessed by various people who are involved in your care (example: doctors, nurses, technicians, students, clerks, laboratory personnel, etc.). Different departments may share medical information about you to coordinate your care. For example, a doctor may share your medical information with another physician if you are referred for specialized care. 

We participate in certain Health Information Exchanges or Organizations (“HIEs” or “HIOs”). Specifically, we participate in the Indiana Health Information Exchange (“IHIE”) and Indiana Network for Patient Care (“INPC”), which help make your PHI available to other healthcare providers who may need access to it to provide care or treatment to you. 
 

2. For Payment: 

We will use and disclose your medical information so that we can bill for the services you received and collect payment. For example: we may share information with your insurance company to obtain prior approval for treatment when applicable, or to bill and receive payment for treatment you received. We may also share your information with other affiliated or contracted entities who performed a service for you during your visit to our facility (examples include other physicians, technicians, labs, and diagnostic services such as x-ray, CT, or MRI). 
 

3. For Operations: 

We may use and disclose your medical information as necessary for health care operations purposes. These uses and disclosures are necessary to run our facilities and make sure that all our patients receive quality care. For example, we may use and disclose medical information to review our treatment and services and to evaluate the performance of our staff in caring for patients or for accreditation, credentialing, or board certification activities. We also may combine medical information about many hospital patients to decide what additional services the hospital should offer, what services are not needed and whether certain treatments are effective. We may disclose information to doctors, nurses, technicians, medical students, and other hospital personnel for review and learning purposes. 
 

4. Uses and Disclosures Not Requiring Authorization: The law allows us to use or disclose your PHI without your authorization in certain situations, including but not limited to: 

• When required by law: We may disclose PHI when a law requires or allows us to do so. For example, we may report information about suspected abuse and/or neglect, relating to suspected criminal activity, for FDA-regulated products or activities, or in response to a court order. 
• For public health activities: We may disclose PHI when we are required or allowed to collect information about disease or injury or to report vital statistics to the public health authority, such as reports of tuberculosis cases or births and deaths. 
• For health oversight activities: We may disclose PHI to the Indiana State Department of Health or other agencies responsible for monitoring us for such purposes as reporting or investigating unusual incidents. 
• To a Business Associate. Certain services are provided to us through contracts with third-party entities known as “business associates” that require access to your health information in order to provide such services. Examples include transcription agencies, copying services and cloud service providers. We require these business associates to agree to protect your health information in compliance with all laws. 
• Relating to decedents: We may disclose PHI relating to an individual's death to coroners, medical examiners, funeral directors, and organ procurement organizations. 
• For research purposes: In certain circumstances, and under supervision of an Institutional Review Board, we may disclose PHI to assist medical research, such as comparing the health and recovery of all patients who received one medicine to those who received another. 
• To avert a threat to health or safety: In order to avoid a serious and imminent threat to the health or safety of an individual or the public, we may disclose PHI to law enforcement or other persons who can reasonably prevent or lessen the threat of harm. 
• Law enforcement: We may disclose PHI to a law enforcement official in circumstances such as: in response to a court order; to identify a suspect, witness, or missing person; about crime victims; about a death that we may suspect is the result of a crime; or a crime that takes place at one of our facilities. 
• For specific government functions: We may disclose PHI of military personnel and veterans in certain situations; to correctional facilities in certain situations; and for national security and intelligence reasons, such as protection of the President. 
• Workers’ Compensation: We may disclose your PHI to your employer or your employer’s insurance carrier for Workers’ Compensation or similar programs that provide benefits for work-related illness or injuries. 
• Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release your PHI in order for them to provide you with healthcare, to protect your health and safety or the health and safety of others, or to ensure the safety and security of the correctional institution. 
• De-Identified PHI: We may de-identify your health information as permitted by law. We may use or disclose to others the de-identified information for any purpose, without your further authorization or consent, including but not limited to, research studies, development of artificial intelligence tools, and health care/health operations improvement activities. 
• Patient Directories: If you are hospitalized, your name, location, general condition, and religious affiliation may be put into our patient directory for use by clergy or by callers or visitors who ask for you by name. If you ask to be a “No Information” or “No Release” patient, volunteers, caregivers, and telephone operators will not tell anyone you are in the facility and flowers, mail, phone calls, and visitors will be turned away and not accepted if your room number is not provided. 
• To families, friends or others involved in your care: We may share with your family, your friends or others involved in your care information directly related to their involvement in your care or payment for your care. We may also share PHI with these people to notify them about your location, general condition, or your death. 
• Disaster relief: In the event of a disaster, we may release your PHI to a public or private relief agency, for purposes of notifying your family and friends of your location, condition, or death. 

Uses and Disclosures Requiring You to Have an Opportunity to Object: In the following situations, we may use or disclose your PHI if we tell you about the use or disclosure in advance and you have the opportunity to agree to, prohibit, or restrict the use or disclosure, and you do not object. However, if there is an emergency situation and you cannot be given the opportunity to agree or object, we may use or disclose your PHI if it is consistent with any prior expressed wishes and the use or disclosure is determined to be in your best interests; provided that you must be informed and given an opportunity to object to further uses or disclosures for patient directory purposes as soon as you are able to do so. 
 

5. Other Uses of Medical Information: 

Other uses and disclosures of medical information not covered by this Notice or law will be made only with your written permission. If you provide us permission to use or disclose your medical information, you may revoke that permission, in writing, at any time. If you revoke your 

permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures we may have already made while we had your permission, and that we are required by law to retain our records of the care we provided to you. 

Your written authorization will be required to use or disclose most psychotherapy notes as well as uses and disclosures of medical information for marketing purposes or sale of medical information. 
 

Your Rights Regarding Your Medical Information 

1. Right to Inspect and Copy: 

You may read your information or request a copy of your records. This includes medical and billing records but does not include psychotherapy notes. If you request a copy of the records, we will respond to your request within thirty (30) days. If we deny your request, we will give you written reasons for the denial and explain any right to have the denial reviewed. If you want copies of your PHI, we may charge a reasonable, cost-based fee. If you request an electronic copy of your PHI that we maintain electronically, we will provide an electronic copy, and will do so in the electronic form or format you requested if the PHI is readily producible in that form or format. You have a right to choose what portions of your information you want copied and to have information on the cost of copying in advance. To review or request a copy of your record, contact the Medical Records Department at Union Hospital 812.238.7648 / Union Hospital Clinton 765.832.1234. 
 

2. Right to Amend: 

If you believe that medical information in your records 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. To request an amendment, contact the Compliance Department at 812.238.7533. A representative will give you the appropriate form to request an amendment (which must include the reason for your request). We will respond within sixty (60) days of receiving your request. We will deny your request for an amendment if it is not in writing or does not include a reason for the request. In addition, we may deny your request if we determine that our information is accurate and complete, that it was not created by us, or not permitted to be disclosed. 
 

3. Right to Accounting of Disclosures: 

You have the right to request an accounting of disclosures, that is, a list of the persons to whom we sent some or all of your medical information during the past six (6) years, except for disclosures: for treatment, payment and health care operations; to you; that are incidental in nature; pursuant to an authorization; for our directory or to persons involved in care; for national security or intelligence purposes; to corrections institutions or law enforcement officials; or as part of a limited data set. Contact the Compliance Department at 812.238.7533 to begin this process. We will charge you for the cost of providing more than one accounting during a 12-month period. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any charges are incurred. 
 

4. Right to Request Restrictions: 

You have the right to request a restriction or limitation of the medical information we use or disclose about you for treatment, payment, or other health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that we not use or disclose information about this visit. In most cases, 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 emergency treatment. If you have paid in full for a service and have requested that we not share PHI related to that service with a health plan, we must agree to such request. To request restrictions, contact the Compliance Department at 812.238.7533. You will be given the appropriate form to complete your request which must include: 

• What information you want to limit; 
• Whether you want to limit our use, disclosure, or both; and 
• To whom you want the limits to apply, for example, disclosures to your spouse. 
 

5. Right to Request Confidential Communications: 

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. You may request confidential communication during your registration process. Any request made after you have been registered, should be made to the Compliance Department at 812.238.7533. 

 

For More Information or to Report a Problem 

If you have questions or would like additional information about our privacy practices or this Notice, you may contact our Compliance Department during normal business hours, 

Monday - Friday, 8 a.m.-5 p.m. at 812.238.7533. 
 

If you believe your privacy rights have been violated, you can file a complaint with the Privacy Officer located in our Compliance Department, at: 

1606 N. 7th Street 
Terre Haute, IN 47804 
812.238.7533 
 

or with the Office of Civil Rights at: 

Centralized Case Management Operations 
U.S. Department of Health and Human Services 
200 Independence Avenue S.W. 
Room 509F HHH Bldg. 
Washington, D.C. 20201 
 

You will not be penalized for filing a complaint. 
 

Changes to this Notice 

We reserve the right to change our practices and this Notice. We reserve the right to make the revised or changed notice effective for medical 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.