NOTICE

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.

If you have any questions about this Notice, our policies, or practices please contact the HARDTNER
MEDICAL CENTER Privacy Officer at 1102 N. Pine Rd., Olla, LA 71465, or 318-495-3131.

WHO WILL FOLLOW THIS NOTICE.

This Notice describes our organization’s practices and that of:

•        Any health care professional authorized to enter information into your medical record.

•        All departments and units of the facility.

•        Any member of a volunteer group we allow to help you while you are here.

•        All employees, staff and other facility personnel.

•         Any HARDTNER MEDICAL CENTER owned health care entities and HARDTNER MEDICAL
CENTER Medical Group offices.
.

OUR PLEDGE REGARDING MEDICAL AND BILLING INFORMATION:

We understand that information about you and your health is personal. We are committed to protecting
medical and billing information about you. We create a record of the care and services you receive at
our facility. This record contains medical and billing information and is used to provide you with quality
care and to comply with certain legal requirements. This Notice applies to all of the records of your care
generated by the facility, whether made by facility personnel or your personal care provider. Your
personal care provider may have different policies or Notices regarding the provider’s use and
disclosure of your medical information created in the practice office or clinic.

This Notice will tell you about the ways in which we may use and disclose medical and billing information
about you.   We also describe your rights and certain obligations we have regarding the use and
disclosure of your medical information.

We are required by law to:

•        make sure that medical and billing information that identifies you is kept private;

•        give you this Notice of our legal duties and privacy practices with respect to medical and billing
information about you; and

•        follow the terms of the Notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL AND BILLING INFORMATION ABOUT YOU

The following categories describe different ways that we use and disclose medical and billing
information. For each category of uses or disclosures we will explain what we mean and try to give 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 information will fall within one of the categories.

For Treatment.   We may use medical information about you to provide you with medical treatment or
services. We may disclose medical information about you to doctors, nurses, healthcare technicians,
healthcare professional students, or other facility personnel who are involved in taking care of you at
our facility. 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. In addition, the doctor may need to tell the dietitian if
you have diabetes so that we can arrange for appropriate meals. Different departments of the facility
also may share medical information about you in order to coordinate the different things you need, such
as prescriptions, lab work and x-rays. This information is shared on the basis of another healthcare
staff “needing to know” the information to provide safe necessary treatment to you. We also may
disclose medical information about you to people outside the facility who may be involved in your
medical care after you leave the facility, such as family members, or other healthcare professionals we
use to provide services that are part of your care.

For Payment. We may use and disclose medical information about you so that the treatment and
services you receive at our facility 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 at our facility so your health plan will pay us or reimburse you for the
surgery. We may also tell your health plan about a treatment you are going to receive to obtain prior
approval or to determine whether your plan will pay for the treatment. This does NOT mean that all
information in your medical record will be shared to gain approval or seek payment but only that which is
necessary.

For Health Care Operations. We may use and disclose medical information about you for facility
operations. These uses and disclosures are necessary to run the facility and make sure that all of our
patients receive quality care. For example, we may use medical information to review our treatment and
services and to evaluate the performance of our staff in caring for you. We may also combine medical
information about many facility patients to decide what additional services the facility should offer, what
services are not needed, and whether certain new treatments are effective. We may also disclose
information to doctors, nurses, technicians, professional healthcare students, and other facility
personnel for review and learning purposes. We may also combine the medical information we have
with medical information from other facilities to compare how we are doing and see where we can make
improvements in the care and services we offer. 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 you or other patients are as individuals.

Appointment Reminders. We may use and disclose medical information to contact you as a reminder
that you have an appointment for treatment or medical care.

Treatment Alternatives. We may use and disclose medical information to tell you about or recommend
possible treatment options or alternatives that may be of interest to you or offer you optional care
alternatives.

Health-Related Products and Services. We may use and disclose medical information to tell you about
health-related products or services that may be of interest to you. If you do not want the facility to
contact you as part of our marketing efforts, you must notify Hardtner Medical Center HIM Manager,
1102 N. Pine Rd., Olla, LA 71465 in writing.

Fundraising Activities. We may use medical information about you to contact you in an effort to raise
money for the facility and its operations. We may disclose medical information to a foundation related to
the facility so that the foundation may contact you to raise money for the facility. We only would release
contact information, such as your name, address and phone number and the dates you received
treatment or services at the facility. If you do not want the facility to contact you for fundraising efforts,
you must notify Hardtner Medical Center HIM Manager, 1102 N. Pine Rd., Olla, LA 71465 in writing.

Facility Directory. Unless you tell us otherwise, we may include certain limited information about you in
the facility directory while you are a patient at the facility. This information may include your name,
location in the facility, your general condition (Examples are fair, stable, critical, etc.) and your religious
affiliation. The directory information, except for your religious affiliation, may also be released to people
who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a
minister, priest or rabbi, even if they don’t ask for you by name. This is so your family, friends and
clergy can visit you in the facility and generally know how you are doing. You have the right to request
that you not be identified to any of these individuals by notifying Hardtner Medical Center Admitting
Office.

Individuals Involved in Your Care or Payment for Your Care. Unless you tell us otherwise, we may
release medical information about you to a friend or family member who is involved in your medical
care. We may also give information to someone who helps pay for your care. We may also tell your
family or friends your condition and that you are in the facility. In addition, we may disclose medical
information about you to an entity assisting in a disaster relief effort so that your family can be notified
about your condition, status and location.

Business Associates. There are some services provided in our organization through contracts with
business associates. Examples include: physician services in the emergency department, radiology
department, certain laboratory tests, transcription services, and a copy service we use when making
copies of your health record. When these services are contracted, we may disclose your health
information to our business associate so that they can perform the job we’ve asked them to do, and bill
you or your third-party payer for services rendered. To protect your health information, however, we
require the business associate to appropriately safeguard your information.

Research. Under certain circumstances, we may use and disclose medical information about you for
research purposes. For example, a research project may involve comparing the health and recovery of
all patients who receive one medication to those who received another, for the same condition. All
research projects, however, are subject to a special approval process. This process evaluates a
proposed research project and its use of medical information, trying to balance 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. But we may,
however, disclose medical information about you to people preparing to conduct a research project.
For example, researchers may look for patients with specific treatment needs, so long as the medical
information they review does not leave the facility. We will almost always 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 at the facility.

As Required By Law. We will disclose medical information about you when required to do so by federal,
state or local laws.

To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you
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.

Organ and Tissue Donation. If you are an organ donor, we may release 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, active or reserve, we may release
medical information about you as required by military command authorities. We may also release
medical information about foreign military personnel to the appropriate foreign military authority.

Workers’ Compensation. We may release medical information about you for workers’ compensation or
similar programs. These programs provide benefits for work-related injuries or illnesses.

Public Health Risks. We may disclose medical information about you 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 or law enforcement 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 medical
information about you in response to a court or administrative order. We may also disclose medical
information about you 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 release medical information if asked to do so 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 the victim of a crime 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 at the facility; 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 release 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 release medical information about you as a patient of the facility to
funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities. We may release medical information about you to
authorized federal officials for intelligence, counterintelligence, and other national security activities
authorized by law.

Protective Services for the President and Others. We may disclose medical information about you to
authorized federal officials so they may provide protection to the President, other authorized persons,
and foreign heads of state or to conduct special investigations.

Inmates. If you are an inmate of a correctional institutional or under the custody of a law enforcement
official, we may release medical information about you to the correctional institution or law enforcement
official. This release 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.

Other uses of medical information. Other uses and disclosures of medical information not covered by
this Notice or the laws that apply to us will be made only with your written permission.   If you provide us
permission to use or disclose medical information about you, 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. 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 for at least six years.

YOUR RIGHTS REGARDING MEDICAL AND BILLING INFORMATION ABOUT YOU

You have the following rights regarding your medical and billing information we maintain.

Right to Inspect and Copy Your Medical and Billing Information. You have the right to inspect and copy
medical information that may be used to make decisions about your care. Usually, this includes medical
and billing records, but does not include psychotherapy notes.

To inspect and copy medical and billing information that may be used to make decisions about you, you
must submit your request in writing to Hardtner Medical Center HIM Manager, 1102 N. Pine Rd., Olla,
LA 71465. If you request a copy of the information, we may charge a fee for the costs of copying,
mailing or other supplies associated with your request.

We may deny your request to inspect and copy this information in certain limited circumstances. If you
are denied access to medical or billing information, you may request that the denial be reviewed.
Another licensed health care professional chosen by the facility will review your request and the denial.
The person conducting the review will not be the person who denied your request. We will comply with
the outcome of the review.

Right to Amend Your Medical and Billing Information. If you feel that medical and billing 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 the information is kept by or for the facility.

To request an amendment, your request must be made in writing and submitted to Hardtner Medical
Center HIM Manager, 1102 N. Pine Rd., Olla, LA 71465. 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 or billing information kept by or for the facility;

•        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 of Your Medical and Billing Information. You have the right to
request an “accounting of disclosures.” This is a list of the disclosures we made of medical and billing
information about you.

To request this list or account of disclosures, you must submit your request in writing Hardtner Medical
Center HIM Manager, 1102 N. Pine Rd., Olla, LA 71465. Your request must state a time period, which
may not be longer than six years and may not include dates before April 14, 2003.    The first list you
request within a 12-month period will be free. For additional lists, we may charge you for the costs of
providing the list. We will notify you of the costs 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 or
billing information we use or disclose about you for treatment, payment or health care operations. You
also have the right to request a restriction on the medical or billing information we disclose about you to
someone who is involved in your care or payment for your care, like a family member or friend. For
example, you could ask that we not use or disclose information about your particular surgery. We are
not required to agree to your request. If we cannot agree to your requested restriction, we will notify
you. If we do agree, we will comply with your request unless the information is needed to provide you
emergency treatment. We may terminate our agreement for a restriction if we inform you and you agree.

To request restrictions, you must make your request in writing to Hardtner Medical Center HIM Manager,
1102 N. Pine Rd., Olla, LA 71465.

Right to Request Confidential Communications. You have the right to request that we communicate with
you about medical treatment and options in a certain way or at a certain location. For example, you can
ask that we contact you at a different phone number or address.

To request confidential communications, you must make your request in writing to Hardtner Medical
Center HIM Manager, 1102 N. Pine Rd., Olla, LA 71465. 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.

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 at our website, http://www.hardtnermedical.com______.

To obtain a paper copy of this Notice, contact our Privacy Officer at Hardtner Medical Center HIM
Manager, 1102 N. Pine Rd., Olla, LA 71465.

Right to Revoke Authorizations and Consents. You have the right to revoke your consent or
authorization to use and disclose health information. If you provide us permission to use or disclose
medical information about you, you may revoke that consent or authorization, 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 or consent. You understand that we are unable to take
back any disclosures we have already made with your permission, and that we are required by law to
retain our records of the care we provided to you.

CHANGES TO THIS NOTICE

We reserve the right to change this Notice at any time. We reserve the right to make the revised or
changed Notice effective for medical or billing information we already have about you as well as any
information we receive in the future. A copy of the current Notice is posted in the facility. The Notice will
contain on the first page, in the top right-hand corner, the effective date. In addition, each time you
register at or are admitted to the facility for treatment or health care services as an inpatient or
outpatient, we will offer you a copy of the current Notice in effect. You may also obtain a copy of the
current Notice through our website at http://www.hardtnermedical.com or by request to Hardtner Medical
Center HIM Manager, 1102 N. Pine Rd., Olla, LA 71465.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the facility Hardtner
Medical Center HIM Manager, 1102 N. Pine Rd., Olla, LA 71465 or with the Secretary of the Department
of Health and Human Services. To file a complaint with the facility, contact Hardtner Medical Center HIM
Manager, 1102 N. Pine Rd., Olla, LA 71465.

The Secretary of the Department of Health and Human Services may be contacted at 200
Independence Ave., S.W.; Washington, D.C. 20201 or by phone at 1-877-696-6775.