FEDERAL TRUTH IN LENDING ACT NOTIFICATION

The Federal Truth in Lending Act requires prompt correction of billing mistakes.1. If you want to preserve your rights under the Act, here’s what to do if you think your bill is wrong or if you need

more information about an item on your bill: a. Do not write on the bill. On a separate sheet of paper write the following: i. Your name and account number. ii. A description of the error and an explanation, as best you can, of why you believe it is an error. If you only need more information, please explain the item you are not sure about. Do not send in your copy of the itemized statement or other documents unless you have a duplicate copy for your records. iii. The dollar amount of the suspected error. iv. Any other information (such as your address) which you think will help us identify you or the reason for your complaint or inquiry. b. Send your billing error notice to the address listed on your billing statement. Mail it as soon as you can, but in any case early enough to reach us within 60 days after the bill was mailed to you. YOU MAY TELEPHONE YOUR INQUIRY, BUT DOING SO WILL NOT PRESERVE YOUR RIGHTS UNDER THIS LAW NOR OBLIGATE US TO FOLLOW THE OUTLINED PROCEDURES.2. We must acknowledge all letters pointing out possible errors within 30 days of receipt unless we are able to correct

your bill within 30 days. Within 90 days after receiving your letter, we must either correct the error or explain why we believe the bill to be correct. Once we have examined the bill, we have no further obligation to you even though you still believe there is an error, except as provided in paragraph 4, below.

3. After we have been notified, in writing, neither we nor an attorney nor a collection agency may send you collection letters or take other collection action with respect to the amount in dispute; but periodic statements may be sent to you. You cannot be threatened with damage to your credit rating or sued for the amount in question, nor can the disputed amount be reported to a credit bureau or to other creditors as delinquent until we have answered your inquiry. However, you remain obligated to pay the part of your bill not in dispute.

4. If our explanation does not satisfy you and you notify us in writing within 10 days after you receive our explanation that you still refuse to pay the disputed amount, we may report you to credit bureaus and other creditors and may pursue regular collection procedures. But we must also report that you think you do not owe the money, and we must let you know to whom such reports were made. Once the matter has been settled between you and us, we must notify those to whom we reported you as delinquent of the subsequent resolution.

DISCLOSURES REQUIRED BY FEDERAL LAW

Your account is subject to the following terms and conditions:

1. If an account is referred for collection, you shall pay all collection and court costs, including a reasonable attorney’s fee. Otherwise than herein and above specified, you shall incur no additional charges to your account.

2. No security interest in any property is retained or acquired for purposes of securing payment of any credit extended on your account, except: (1) any security interest acquired by virtue of Montana’s Liens of Certain Health Care Providers law, MCA Title 71, Ch. 3, Part 11, and (2) any security interest in property retained by the hospital to secure payment of your account.

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As a patient, you have certain rights and responsibilities. We encourage you speak openly with your health care team, take part in your treatment choices, and promote your own safety by being well informed and involved in your care.

You have the right…• To receive considerate, respectful and compassionate care regardless of your age, gender, race, national origin, religion, or

any other category protected by law.• To receive care in a safe environment free from all forms of abuse, neglect, or mistreatment.• To be told the names and professional status of all health care providers directing and/or providing your care.• To discuss ethical issues surrounding your care. A member of the Medical Staff Ethics Committee is available at all times.• To be told by your health care provider about your diagnosis and possible prognosis, the benefits and risks of treatment, and

the expected outcome of treatment, including unexpected outcomes. You have the right to give written informed consent before any non-emergency procedure begins.

• To be free from restraints and seclusion in any form that is not medically required.• To expect full consideration of your privacy and confidentiality in care discussions, exams, and treatments. You may ask for a

chaperone during any type of exam.• To access protective and advocacy services in cases of abuse or neglect. KRH will provide a list of these resources.• To participate in decisions about your care, your treatment, and services provided, including the right to refuse treatment to

the extent permitted by law. If you leave the hospital against the advice of your health care provider, KRH and your health care provider will not be responsible for any medical consequences that may occur.

• To agree or refuse to take part in medical research studies; or to withdraw from a study at any time without impacting your access to standard care.

• To communication that you can understand. KRH will provide language interpreters as necessary at no cost to you.• To make an advance directive and appoint someone to make health care decisions for you if you are unable. If you do not

have an advance directive, we can provide you with information and help you complete one.• To receive information in a timely manner regarding your discharge, transfer to another facility, or transfer to another level of

care. Before your discharge, you can expect to receive information about follow-up care that you may need.• To receive detailed information about your hospital and health care provider charges.• To expect that all communication and records about your care are confidential, unless disclosure is permitted by law. You

have the right to see or get a copy of your medical records. You may request an amendment to your medical record by contacting the Health Information Management. You have the right to request a list of people to whom your personal health information was disclosed.

• To give or refuse consent for recordings, photographs, films, or other images to be produced or used for internal or external purposes other than identification, diagnosis, or treatment. You have the right to withdraw consent up until a reasonable time before the item is used.

• To spiritual services. Chaplains are available to help you directly or to contact your own clergy.• To voice your concerns about the care you receive. If you have a problem or complaint, you may talk with your doctor,

nurse manager, or a department manager. You may also contact the Customer Relations Office at 406-751-5434 or email customerrelations@krmc.org.

You have the responsibility…• To provide complete and accurate information that facilitates your care, treatment and services.• To ask questions or acknowledge when you do not understand the treatment course or care decisions. If you believe you

cannot follow through with your treatment plan, you are responsible for telling your health care provider. You are responsible for outcomes if you do not follow the care, treatment, and service plan.

• To follow instructions, policies, rules and regulations in place to support quality for patients and a safe environment for all individuals in the hospital.

• To treat all hospital staff, other patients, and visitors with courtesy and respect; abide by all hospital rules and safety regulations; be mindful of noise levels, privacy, and number of visitors; and be respectful of the property of other persons and of the hospital.

• To provide complete and accurate information about your health insurance coverage and to pay your bills as promptly as possible.

• To keep appointments and, when unable to do so, to notify the responsible health care provider or health care facility.• To provide a copy of advance directives, if applicable.

PATIENT RIGHTS & RESPONSIBILITIES

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This document presents a condensed listing of patient rights and responsibilities from Administrative Policy A401, Patient Rights & Responsibilities. To review a complete and current copy of this policy, contact KRH Administration, 406-752-1724.

At Kalispell Regional Healthcare, our administrative team participates actively in the Customer Relations program. Visits with patients help us understand the health care experience from our customer’s point of view. Please share your comments and concerns with our team members when they visit.

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.

WHO WILL FOLLOW THIS NOTICEAs allowed by law and to better serve your health care needs, the following organizations have designated themselves as an Organized Health Care Arrangement, which allows them to: (1) share your Medical Information with each other for the purposes of treatment, payment, or health care operations, and (2) requires them to follow the terms of this Joint Notice of Privacy Practices (“Notice”).

• Kalispell Regional Healthcare System• Kalispell Regional Medical Center (“KRMC”), including its physician clinics, listed below• KRMC doing business as Home Options and Lake County Home Options• KRMC doing business as Pathways Treatment Center• KRMC doing business as Polson Health Outpatient Center The physician clinics of Kalispell Regional Medical Center and The HealthCenter currently include, but are not limited to: Bass Breast Center; Big Sky Family Medicine; Bigfork Medical Clinic; Diabetes Care and Prevention Center; Employee Health & Wellness; Lance Ercanbrack MD– General Surgery; FamilyBorn Maternity and Women’s Health; Family Health Care; Flathead Valley Orthopedics Clinic; Geriatric and Supportive Care; Gina Nelson MD; Glacier View Plastic Surgery; Greater Flathead Renal; Kalispell Gastroenterology; Kalispell Medical Office and Bone Health; Kalispell Regional Healthcare Surgical Specialists; The Montana Center for Wellness and Pain Management; Montana Perinatal Center; Neuroscience & Spine Institute; Department of Neurological Surgery & Department of Neurology; Department of Physical Medicine and Rehab; The Newman Center; Northwest Center for Specialty Oncology Care: Division of Surgical Oncology & Division of Therapeutic Gastrointestinal Endoscopy; Kalispell Regional Behavioral Health; Northwest Family Medicine; Northwest Hospitalists; Northwest Montana Radiation Oncology; Northwest Montana Surgical Associates; Northwest Oncology and Hematology; Northwest Specialists; Northwest Specialty Clinic – Whitefish; Northwest Women’s Health Care; Pediatric Endocrinology and Diabetes Center; Peri & Neonatal Services at KRMC; Polson Health; Rocky Mountain Heart and Lung; Sunny View Pediatrics; Turtle Bay Behavioral Health; Westshore Medical Clinic; Woodland Clinic; Wound and Ostomy Center.

The above organizations are referred to “we”, “our”, or “us” and include:• Any health care professional authorized to access or enter information into your chart;• All departments and units of the organizations covered by this Notice;• Any member of a volunteer group we allow to help you; and• All of our employees, staff, and other personnel.

OUR LEGAL DUTY REGARDING YOUR MEDICAL INFORMATIONWe are committed to protecting your medical information (“Medical Information”). Medical Information covered by this Notice is information: (1) that identifies you or could be used to identify you; (2) that we collect from you or that we create or receive; and (3) that relates to your past, present or future physical or mental health condition, including health care services provided to you and past, present, or future payment for such health care services.

When you are treated at any of our facilities, we create a record of the care and services you receive. We need this record to provide you with quality care and to comply with applicable legal requirements. This Notice applies to Your Medical Information that is created or received by us. It is possible that your doctor may also create medical information at other hospitals or medical facilities. Those facilities may have different policies or notices regarding their use and disclosure of your medical information created by your doctor while at that facility.

This Notice informs you of: (1) our legal obligations regarding your Medical Information, (2) how we may use and disclose your Medical Information, and (3) what your rights are regarding your Medical Information.

JOINT NOTICE OF PRIVACY PRACTICESEffective Date: August 2018

• KRMC doing business as Outpatient Surgery Center• The HealthCenter, including its physician clinics, listed below • Applied Health Services doing business as Kalispell Medical Equipment• Northwest Horizons doing business as Brendan House• Northwest Orthopedics & Sports Medicine• The Summit Medical Fitness Center

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The law requires us to:• Make sure that your Medical Information is kept private as explained in this Notice;• Give you this Notice of our legal duties and privacy practices regarding your Medical Information;• Follow the terms of this Notice; and• Notify you of any unauthorized disclosure of your Medical Information.

If you have any questions about this Notice, please contact the KRH Privacy Office by phone at (406) 752-1742 or by written correspondence at KRH Privacy Office, Kalispell Regional Healthcare, 310 Sunnyview Lane, Kalispell, MT 59901.

HOW WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATIONThe following categories describe different ways that we are permitted to use and disclose your Medical Information. For each category, we describe the use or disclosure and provide some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose your Medical Information fall within one of the categories.

USES OR DISCLOSURES THAT CAN BE MADE WITHOUT YOUR AUTHORIZATION OR AN OPPORTUNITY TO OBJECTTreatment – We may use your Medical Information to provide you with medical treatment or services. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. We may share your Medical Information in order to coordinate the different things you need, such as prescriptions, lab work and x-rays that are provided by other health care organizations. We may use and disclose your Medical Information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Payment – We may use and disclose your Medical Information so that the treatment and services you receive at an organization listed in this Notice may be billed to and payment may be collected from you, an insurance company or other third party. For example, we may need to give your health plan information about surgery you received so your health plan will pay us or reimburse you for the surgery. We may also provide your health plan with information about a treatment you are going to receive in order to obtain prior approval or to determine whether your plan will cover the treatment. We may also share information about you and any insurance information with other health care providers to assist them in getting payment for a service they have provided you. For example, we may share this information with a laboratory that evaluates a laboratory specimen.

Health Care Operations – We may use and disclose your Medical Information for operation of the organizations listed in this Notice. These uses and disclosures are necessary to run the organizations and to make sure that all of our patients receive quality care. For example, we may use your Medical Information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may give out your Medical Information to our business associates that help us with our administrative and other functions. These business associates may re-disclose your Medical Information as necessary for our health care operations. We may also combine Medical Information about many patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose Medical Information to doctors, nurses, technicians, medical students, and other organization personnel for review and learning purposes. We may also combine the Medical Information we have with medical information from other organizations to compare how we are doing and see where we can make improvements in the care and services we offer. We may use your Medical Information to send questionnaires to you about your experience so that we can identify ways to improve your satisfaction with the services we provide. We may remove information that identifies you from this set of Medical Information so others may use it to study health care and health care delivery without learning who the specific patients are. We may also produce limited data sets that are partially de-identified and that must be used under restrictive agreements for purposes of research, public health, and other health care operations described above. We may use or disclose your Medical Information to other health care providers who also have a relationship with you for activities related to evaluating the quality of care you received, for coordinating your care, evaluating the competence of your health care providers, conducting training, or for regulatory oversight and compliance.

Fundraising Activities – In support of our charitable mission, we may share some of your information with Kalispell Regional Healthcare Foundation to respectfully contact you for gift support using information such as your name and address. Through philanthropy, we seek to advance our patient care programs and services. For example, we use charitable gifts to fund heart and cancer care programs and needed charity care. If you would like to opt out of receiving fundraising communications from the Kalispell Regional Healthcare Foundation, you may do so by contacting the Kalispell Regional Healthcare Foundation via: (1) Telephone – 406-751-6930; (2) Email – foundation@krmc.org; or (3) written request to Kalispell Regional Healthcare Foundation, 310 Sunnyview Lane, Kalispell, MT 59901.

Research – Under certain circumstances, we may use and disclose your Medical Information for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another medication for the same condition. All research projects are subject to a special approval process. This process

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evaluates a proposed research project and its use of Medical Information, balancing the research needs with patients’ need for privacy of their Medical Information. Before we use or disclose Medical Information for research, the project will have been approved through this research approval process. We may disclose your Medical Information to people preparing to conduct a research project (e.g., to help them look for patients with specific medical needs) so long as the Medical Information they review does not leave the organizations listed in this Notice. We will ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care.

As Required By Law – We will disclose your Medical Information when required to do so by federal, state, or local law.

To Avert a Serious Threat to Health or Safety – We may use and disclose your Medical Information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. Disclosures regarding infectious diseases must comply with applicable state laws limiting the disclosure of patient identity and related information.

Organ and Tissue Donation – If you are an organ donor, we may disclose your Medical Information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans – If you are a member of the armed forces, we may disclose your Medical Information as required by military command authorities. We may also disclose medical information about foreign military personnel to the appropriate foreign military authority.

Workers’ Compensation – We may disclose your Medical Information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Activities – We may disclose your Medical Information for public health activities. These activities generally include the following:

• To prevent or control disease, injury or disability;• To report births and deaths;• To report child abuse or neglect;• To report reactions to medications or problems with products;• To notify people of recalls of products they may be using;• To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;• To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities – We may disclose Medical Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes – If you are involved in a lawsuit or a dispute, we may disclose your Medical Information in response to a court or administrative order. We may also disclose your Medical Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement – We may disclose Medical Information, if asked by a law enforcement official:• In response to a court order, subpoena, warrant, summons or similar process;• To identify or locate a suspect, fugitive, material witness, or missing person;• About a crime victim if, under certain limited circumstances, we are unable to obtain the person’s agreement;• About a death we believe may be the result of criminal conduct;• About criminal conduct on site at one of the organizations listed in this Notice; and• In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners, and Funeral Directors – We may disclose Medical Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose Medical Information about patients to funeral directors as necessary to carry out their duties.

National Security & Intelligence – By law, we may disclose your Medical Information to authorized federal officials for intelligence, counterintelligence, or other national security activities.

Protective Services for the President and Others – We may disclose your Medical Information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

Schools – We may disclose Medical Information to a school about an individual who is a student or prospective student of the school if the Medical Information is limited to proof of immunization, the school is required by state or other law to have that proof of immunization prior to admitting the individual, and we obtain and document the agreement to the disclosure from either the individual’s parent/guardian or from the individual if the individual is an adult or emancipated minor.

Inmates – If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your Medical Information to the correctional institution or law enforcement official. This disclose would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

USES OR DISCLOSURES WHEN YOU HAVE AN OPPORTUNITY TO OBJECTFacility Directories and Religious Preferences – Unless you object, we may include the following information in any facility directory: your name, location in the facility, and your condition stated in general terms that does not communicate any specific medical information about you. We may also list any religious preference you tell us in directories provided to clergy.

Individuals Involved in Your Care or Payment for Your Care – Unless you object, we may disclose your Medical Information that is relevant to a family member, relative, close personal friend, or any other person identified by you who is involved in your health care or payment related to your health care. We may also tell your family or friends your general condition and that you are in the hospital. In addition, we may disclose your Medical Information to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

Medical Information of a Deceased Individual – As allowed by law and in certain circumstances, we may disclose the Medical Information of a deceased individual to family members, relatives, close personal friends, or any other persons who were either authorized by law to act for the deceased individual or who were previously identified as being involved in the individual’s care or payment for the individual’s health care.

USES OR DISCLOSURES THAT REQUIRE YOUR AUTHORIZATIONMental Health Treatment – Uses or disclosures for mental health treatment can be made only to professionals for treatment, to obtain payment for services provided, or as otherwise required by state law.

Psychotherapy Notes – Should your treatment involve the creation of psychotherapy notes (a subset of mental health treatment records), we will obtain your written authorization for the use and disclosure of psychotherapy notes in most cases. The exceptions are: (1) to carry out the following treatment, payment or health care operations activities: (a) use by the originator of the psychotherapy notes for treatment, (b) use or disclosure for our training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling; or (c) use or disclosure to defend ourselves in a legal action or other proceeding brought by you; (2) required uses or disclosures required the Secretary of the Department of Human Health and Services for determinations of our compliance with the law, or (3) permitted uses or disclosures: (a) to health oversight agencies as permitted by law for oversight of the originator of the psychotherapy notes, (b) to coroners and medical examiners for the identification of a deceased person, or (c) made in good faith to avert a serious threat to public safety.

Marketing – We are required to obtain your authorization for any use or disclosure of your Medical Information for marketing purposes, unless the communication is in the form of a face-to-face communication made by us to you or if we provide you with a promotional gift of nominal value.

Sale of Medical Information – We are required to obtain your authorization for any disclosure of your Medical Information that constitutes a sale of Medical Information.

Drug or Alcohol Abuse Treatment – Federal law and regulations protect the confidentiality of drug and alcohol abuse patient records maintained by us. Generally, we may not disclose information regarding drug and alcohol abuse related treatment, a patient’s presence in a drug and alcohol abuse treatment program, or a patient’s status as an alcohol or drug abuser; unless: (1) the patient consents in writing; (2) the disclosure is allowed by a court order; or (3) the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation. Federal law and regulations do not protect any information about a crime committed by a patient in a drug and alcohol abuse program or against any person who works for a drug and alcohol abuse program or about any threat to commit such a crime. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.8690-051 pg 4 of 6 6/19

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REPORTING OF IMMUNIZATION RECORDSSharing Your Immunization Data with the Montana DPHHS Immunization Information System (“IIS”):The Montana Department of Public Health and Human Services (DPHHS) maintains a confidential, computerized system that collects and consolidates immunization data from providers of immunizations, like us, in order to design and sustain effective immunization strategies for public health purposes. DPHHS has requested that we seek your consent to share your/your child’s immunization data with the DPHHS IIS database. THEREFORE, WE ARE PROVIDING YOU WITH AN OPPORTUNITY TO OPT OUT OF THIS SHARING OF YOUR/YOUR CHILD’S IMMUNIZATION DATA ON THE PATIENT CONSENT AND FINANCIAL SERVICES AGREEMENT THAT YOU ARE BEING ASKED TO REVIEW AND SIGN.

YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATIONYou have the following rights regarding your Medical Information:

Right to access to inspect and copy – In most cases, you have the right to inspect and obtain a copy of your Medical Information. Usually, this includes medical and billing records, but does not include psychotherapy notes. To inspect and obtain a copy of your Medical Information, please submit your request in writing to the KRH Privacy Office listed on page 1 of this Notice.

We may deny your request to inspect and copy your Medical Information in certain circumstances. If you are denied access to your Medical Information, in some cases, you may request that the denial be reviewed. Another licensed health professional chosen by us will review your request and the denial. The person conducting the review will not be the person who initially denied your request. We will comply with the outcome of the review.

If you request a copy of your Medical Information, we may charge a reasonable fee for the costs of copying, mailing, or other supplies associated with your request.

Right to Amend – If you feel that Medical Information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as we keep the Medical Information. To request an amendment, your request must be made in writing and submitted to the KRH Privacy Office listed on page 1 of this Notice. In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;• Is not part of the Medical Information kept by or for the organization;• Is not part of the information which you would be permitted to inspect and copy; or• Is accurate and complete.

Right to an Accounting of Disclosures – You have the right to request an “accounting of disclosures.” This is a list of certain disclosures we made of your Medical Information. To request this list or accounting of disclosures, you must submit your request in writing to the KRH Privacy Office listed on page 1 of this Notice.

• We are not required to provide an accounting of disclosures: (1) to carry out treatment, payment or health care operations, (2) made to you, (3) incident to a permitted or required disclosure, (4) made pursuant to your authorization, the organization’s directory or to persons involved in your care or other notification purposes, (5) for national security or intelligence purposes, (6) to correctional institutions or law enforcement officials, or (7) that are part of a limited data set that does not include any information that directly identifies you, your relatives, or employers.• Your request must state a time period that may not be longer than six years prior to the date of your request.• Your request should indicate in what form you want the list (e.g., on paper, electronically)• The first list you request within a 12-month period will be free• For additional lists, we may charge you for the cost of providing the list• We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred

Right to Request Restrictions – You have the right to request a restriction or limitation on the Medical Information we use or disclose about you for treatment, payment or 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, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.

To request restrictions, you must make your request in writing to the KRH Privacy Office listed on page 1 of this Notice. 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. A restriction is not granted until you

receive written notice of its approval. If we do agree to your request for restrictions, we will comply with your request unless the information is needed to provide you emergency treatment.

We are not required to agree to your request for restrictions, except when you have requested that we not disclose your Medical Information to your health plan for payment purposes or health care operations and you or some other person on your behalf has paid for your medical services out-of-pocket and in full.

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. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. To request confidential communications, you must make your request in writing to the KRH Privacy Office listed on page 1 of this Notice.

Right to a Paper Copy of This Notice – You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. You may obtain a copy of this Notice on our web site at www.kalispellregional.org, or by contacting the KRH Privacy Office listed on page 1 of this Notice.

Right to a Notice of Breach – You have the right to receive written notification of a breach if your unsecured Medical Information has been accessed, used, acquired, or disclosed to an unauthorized person as a result of a breach, and if the breach compromises the security or privacy of your Medical Information. Unless you request in writing to receive the notification by electronic mail, we will provide the written notification by first-class mail or, if necessary, by other substituted forms of communication allowable under the law.

Photographs – Medical photographs or other video images may be taken before, during, or after a surgical procedure or treatment to be used as part of the medical record to document appearance and response to treatment. Images in which the patient is not able to be identified and which are not connected to identifying personal information may also be used at our discretion for professional medical or other purposes, including but not limited to, professional medical education, patient education, advertising or other publication in scientific or non-scientific publications, electronic digital networks, or in other electronic or print media including television.

COMPLAINTSIf you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, please contact the KRH Corporate Compliance Office at 406-752-1742. All complaints must be submitted in writing to KRH Corporate Compliance Office, Kalispell Regional Healthcare, 310 Sunnyview Lane, Kalispell, MT 59901.

You will not be retaliated against for filing a complaint.

CHANGES TO THIS NOTICEWe reserve the right to change 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 Medical Information we receive in the future. We will post a copy of the current Notice at each organization covered by this Notice. The Notice will contain the effective date on the first page. In addition, each time you register at or are admitted to one of our organizations for treatment or health care services as an inpatient or an outpatient, we will make available a copy of the current Notice in effect.

OTHER USES OF MEDICAL INFORMATIONOther uses and disclosures of your Medical Information not covered by this Notice or the laws that apply to us will be made only with your written authorization. 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 your Medical Information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

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Policy:It is the policy of Kalispell Regional Healthcare to inform all persons of their rights to make decisions about their treatment, including the right to accept or refuse treatment and the right to formulate an Advance Directive.

Patient care shall not be a condition of, nor shall a patient be discriminated against in any way, because of the presence or absence of an Advance Directive.

Kalispell Regional Healthcare shall make every effort to comply with the Patient Self Determination Act and the Montana Rights of Terminally III Act, in the provision of care to the patients whom we serve.

Definitions: 1. Physician: An individual licensed to practice medicine under Title 37, Chapter 3, of the Montana State Laws.

2. Attending physician: The physician selected by, or assigned to the patient, and who has primary responsibility for the treatment and care of the patient.

3. Declaration: A document executed in accordance with the Patient Self Determination Act and the Montana Rights of the Terminally III Act.

4. Life sustaining treatment: Any medical procedure or intervention that, when administered to a qualified patient, will serve only to prolong the dying process.

5. Qualified patient: A patient 18 years of age or older who has executed a declaration in accor dance with this chapter and who has been determined by the attending physician to be in a terminal

condition.

6. Terminal condition: An incurable or irreversible condition, that without the administration of life sustaining treatment, will, in the opinion of the attending physician, result in death within a relatively short time.

Questions and Answers regarding Advance Directives: 1 Q. What is an Advance Directive? A. An Advance Directive is a document that instructs your physician regarding your wishes to accept or refuse life sustaining treatment if you are in a terminal condition and are unable to express your wishes at the time.

2. Q. Who can create an Advance Directive? A. An individual of sound mind and 18 years of age or older may execute at any time a declara tion governing the withholding or withdrawal of life sustaining treatment (MCA 50‑9‑103). The person making the declaration may designate the attending physician, or another individual of sound mind and 18 years of age or older, to make decisions governing the withholding or with drawal of life sustaining treatment.

INFORMATION REGARDING ADVANCE DIRECTIVES

3. Q. When does an Advance Directive become operative? A. An Advance Directive becomes operative when: a) it is communicated to the attending physician; and b) the person making the declaration is determined by the attending physician to be in a terminal condition and no longer able to make decisions regarding administration of life sustaining treatment.

4. Q. What happens if my physician does not wish to comply with my Advance Directive? A. If the attending physician is unwilling to comply with the patient’s Advance Medical Directive, the physician shall take all reasonable steps as promptly as possible to transfer care of the declarant to another physician or healthcare provider who is willing to do so.

If the other health care provider is unwilling to comply with the patient’s Advance Medical Directive, the other healthcare provider shall take all reasonable steps as promptly as possible to transfer care of the declarant to another health care provider who is willing to do so.

5. Q. May I revoke an Advance Directive already made? A. Yes. A declarant may revoke a declaration at any time and in any manner, without regard to mental or physical condition. A revocation is effective upon its communication to the attending physician or other health care provider by the declarant or a witness to the revocation.

6. Q. If my Advance Directive was made in another state, can it be honored in Montana? A. A declaration executed in a manner substantially similar to the requirements of the Montana Rights of the Terminally III Act, but done in another state, and in compliance with the laws of the state, is effective for the purposes of Montana law.

7. Q. What are some common forms of Advance Directives? A. Common forms of Advance Directives are: a) a Declaration to Physician; b) a Declaration to Individual; c) a Durable Power of Attorney; d) a Judicial Appointment; e) a Living Will Protocol as defined in (MCA 50‑9‑102).

8. Q. How can I create an Advance Directive? A. An individual who is eligible to complete an Advance Directive should discuss the intended Advance Directive with his/her personal physician. The Advance Directive should be communicated to the attending physician in writing and in the appropriate form.

9. Q. If I am a patient of Kalispell Regional Healthcare and have other questions regarding Advance Directives, whom should I contact? A. Please discuss an Advance Directive with your physician, or request from your nurse that a member of the hospital Case Management Department provide you with additional information.

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