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Dear Patient & Family Members:

I would like to take this opportunity to thank you personally for selecting I-70 Community Hospital as your healthcare provider.

As a healthcare provider, we are dedicated to providing you quality care in a compassionate and caring environment. Your questions, suggestions, comments and complaints about your care will be used to identify areas that need improvement. Please be assured that your comments will not interfere with your present or future care at I-70 Community Hospital.

Our primary responsibility is to provide the appropriate care for your physical and mental well being, whether you are a patient of the hospital, or of our family clinic. We strive to protect the confidentiality of your medical records and realize how sensitive patients are about their personal rights or privacy.

At the time of your dismissal from the hospital you will be given a survey to record your thoughts. The surveys are used to gather information about patient satisfaction with the services being provided by the hospital or our family clinic.

We appreciate the time you spend in assisting us. I assure you that your comments will receive our full attention and will be used to improve our health care processes. We genuinely want to provide you with quality care. I would like to thank you and encourage you to respond by using our patient surveys or simply call me at (660) 335-7408 with your questions or comments.

Sincerely,

Chief Executive Officer, I-70 Community Hospital

NONDISCRIMINATION POLICY

 

 

As a recipient of Federal financial assistance, the I-70 Community Hospital does not exclude, deny benefits to, or otherwise discriminate against any person on the grounds of race, color, or national origin, or on the basis of disability or age in admission to, participation in, or receipt of the services and benefits of any of its programs and activities or in employment therein, whether carried out by the I-70 Community Hospital directly or through a contractor or any other entity with whom the I-70 Community Hospital arranges to carry out its programs and activities.

 

This statement is in accordance with the provisions of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Regulations of the U.S. Department of Health and Human Services issued pursuant to the Acts, Title 45 Code of Federal Regulations Part 80, 84 and 91. (Other Federal Laws and Regulations provide similar protection against discrimination of grounds of sex and creed.)

 

To obtain additional information about your rights under Title VI/ADA, contact I-70 Community Hospital.

If you believe you have been discriminated against on the basis of race, color, or national origin by I-70 Community Hospital, you may file a Title VI/ADA complaint by completing, signing, and submitting the agency’s Title VI/ADA Complaint Form.

How to file a Title VI/ADA complaint with I-70 Community Hospital:

1.        To obtain a Complaint Form, contact I-70 Community Hospital, 105 Hospital Drive, Sweet Springs, MO 65351 in writing, by telephone at 660-335-7413, or by downloading the form at www.i70hospital.com.

2.     In addition to the complaint process at I-70 Community Hospital, complaints may be filed directly with the Federal Transit Administration, Office of Civil Rights, Region VII, 901 Locust Street, Suite 404, Kansas City, MO  64106.

3.     Complaints must be filed within 180 days following the date of the alleged discriminatory occurrence and should contain as much detailed information about the alleged discrimination as possible.

4.      The form must be signed and dated, and include your contact information.

If information is needed in another language, contact Administration at 660-335-7413.


I-70 COMMUNITY HOSPITAL TITLE VI COMPLAINT FORM

For non-emergency situations and outpatient visits, please report to the admissions desk in the business office. You will be asked the following:

  • Basic information, such as Name, Address, Date of Birth, Social Security Number, Emergency contacts, place of employment, etc.
  • If the service is related to an accident or injury.
  • For insurance cards or records.
    • If the service is related to an auto accident you will need YOUR auto insurance information.
    • If the service is related to an accident on someone's property, you will need the insurance from THE HOMEOWNER OR BUSINESS where the accident occurred.
  • Medicare patients will be asked to complete a Medicare questionnaire to determine if another insurance should be billed.
  • You are encouraged to bring essential personal items such as:
      • a comb
      • a hair brush
      • deodorant
      • shaving articles
      • toothbrush and toothpaste
      • shampoo
      • lotion
      • soap
      • sleeping apparel
      • slippers
      • a robe

We will be glad to furnish personal items if you choose not to bring them. Medicare and most insurances will not pay for them, you will be responsible for the cost of these items.

  • A list of the medications you are currently taking at home.
  • Medical insurance cards or insurance coverage information.
  • If you have a Living Will or a Durable Power of Attorney for Health Care Decisions bring a copy if you are not sure that it is already on file at the hospital.
  • Please, leave your valuables at home
    We ask that you do not keep more than $5.00 cash in your room. We also ask, for safekeeping, that you send valuables home if at all possible.

Hospital personnel are required to respect your privacy and treat all information in strict confidence. Information in your patient record is available to the staff providing your care on a need to know basis only. We ask for your assistance in respecting the privacy of other patients as well. Please do not ask the staff about other patients, as staff is required to respect their privacy as well as yours.



Your Patient Rights

As a patient at I-70 Community Hospital you have the right to:
  • Suitable treatment and services regardless of your age, gender, national origin, culture, disability, economic status, educational background of the source or payment for your care.
  • Considerable and respectful care from qualified personnel.
  • The name of the physician who is responsible for your care and information about your condition.
  • Information necessary to allow you to actively participate in decisions regarding your medical care.
  • Request a change in physicians or transfer to another health facility for religious or other reasons.
  • Information contained in your medical record within the limits of the law.
  • Request a specialist or an option from another physician at your own expense.
  • Confidentiality pertaining to your diagnosis, care and method of payment.
  • Be informed about the hospital charges for services and available payment methods.
  • Communicate with people outside the hospital by having personal visits and verbal or written communication.
  • Information about medical procedures or treatments that require your consent, including explanation of risks, probable success al alternative treatments.
  • Expectation of reasonable safety while receiving services at the hospital.
  • Be free of restraints, except as ordered by the physician.
  • To refuse treatment. You will be informed of medical consequences for refusing treatment.
  • Care that promotes your physical, emotional and spiritual comfort and dignity.
  • A grievance process.
It is your responsibility to:
  • Provide accurate and complete information about matters relating to your health.
  • Follow your treatment plan.
  • Provide information need to file your insurance claims and work with the hospital to make payment arrangements.
  • Follow hospital rules and regulations, including the No Smoking policy.
  • Be considerate of the rights of other patients, staff and physicians.
  • Be responsible for your actions if you refuse treatment or do not follow the practitioner's instructions.
  • Provide the hospital with a copy of your written advance directives, if you have one.
  • Make complaints known so that concerns can be addressed.
Patient Medical Forms can be found here.

I-70 Community Hospital's Patient Privacy Statement

NOTICE OF PRIVACY PRACTICES FOR I-70 COMMUNITY HOSPITAL

Effective date: November 15th, 2005

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.

I-70 Community Hospital creates a record of the care and services you receive in the facility. Your medical records and billing information are created and retained on I-70 Community Hospital's computer system. That system is accessible to I-70 Community Hospital personnel and members of the medical staff. Proper safeguards are in place to discourage improper use or access. We are required by law to protect your privacy and the confidentiality of your personal and protected health information and records. This notice describes your rights and our legal duties regarding your protected health information.

Definitions: you, at times, may see or hear new terms in relation to this notice. Some of the terms you may hear and their definitions are:

1. Protected Health Information (PHI) is your personal and protected health information that we use to render care to you and bill for services provided
2. Privacy Officer – is the individual in the has responsibility for developing and implementing all polices and procedures your PHI and receiving and investigating any complaints you may have about the use and disclosure of your PHI
3. Business Associate – is an individual or business outside of I-70 Community Hospital that works with I-70 Community Hospital to help provide you with services in I-70 Community Hospital.
4. Authorization- we will obtain an authorization from you giving us permission to use or disclose your protected health information for purposes other than for your treatment, to obtain payment of your bills and for health care operations of I-70 Community Hospital.

I-70 Community Hospital may use and disclose your protected health information for the following:

1. Treatment–We may use protected health information about you to provide medical treatment or services. We may disclose protected health information about you to doctors, nurses, technicians, medical, nursing and other students in care of you at I-70 Community Hospital. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing so that we can arrange for appropriate meals. Different departments of I-70 Community Hospital also may share protected health information about you in order to coordinate the different things you need, such as prescriptions, lab work, and x-rays. We also may disclose protected health information about you to individuals such as family members, clergy or others we use to provide services that are part of your care.
2. Payment- We may use and disclose protected health information about you so that treatment and services you receive at I-70 Community Hospital may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about surgery you received at I-70 Community Hospital so your health plan will pay us or reimburse your 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 cover the treatment.
3. Health Care Options- We may use and disclose protected health information about you for I-70 Community Hospital operations. These uses and disclosures are necessary to run I-70 Community Hospital and make sure that all of our patients receive quality care. For example, we may use protected health information about your high blood pressure to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine protected health information about many I-70 Community Hospital patients to decide what additional services I-70 Community Hospital should offer, what services are not needed, and whether certain new treatments are effective. We may also combine protected health information we have with protected health information from other facilities to compare how we are doing and see where we can make improvements in the care and services we offer.
4. Business Associates- We may disclose your protected health information to Business Associates outside I-70 Community Hospital with whom we contract to provide services on our behalf. However, we will only make these disclosures if we have received satisfactory assurance that the Business Associate will properly safeguard your privacy and the confidentiality of your protected health information. For example, we may contract with a company outside of I-70 Community Hospital to provide medical transcription services for I-70 Community Hospital.
5. Appointment Reminders. We may use and disclose your protected health information to contact you to remind you of an appointment for treatment or medical care at I-70 Community Hospital.
6. Health Related Benefits and Services. We may use and disclose your protected health information to tell you about health-related benefits or services or recommend possible treatment options or alternatives that may interest you.
7. Fundraising Activities of I-70 Community Hospital- We may use or disclose your protected health information to contact you in an effort to raise money for I-70 Community Hospital and its operations. We would only release contact information, such as your name, address and phone number and the dates you received treatment or services at I-70 Community Hospital. If you do not want I-70 Community Hospital to contact you for fundraising efforts, please notify the Privacy Officer.
8. I-70 Community Hospital Directory- We may include certain limited information about you in the I-70 Community Hospital directory while you are a patient at I-70 Community Hospital. This information may include your name, location in I-70 Community Hospital and your general condition (e.g., fair, stable, etc.) which may 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 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 I-70 Community Hospital and generally know how you are doing.
9. Individuals Involved in Your Care or Payment for Your Care- We may disclose protected health information to a friend or family member who is involved in your medical care. We may also give your protected health information to someone who helps pay for your care. We may also disclose protected health information about you to any entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
10. Research- Under certain circumstances, we may use and disclose protected health information about you 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, 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 protected health information, trying to balance the research needs with patients’ need for privacy of their protected health 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 protected health information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the protected health information they review does not leave I-70 Community Hospital. 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 I-70 Community Hospital.
11. As Required by Law- We will disclose protected health information about you when required to do so by federal, state or local law.
12. To Avert a Serious Threat to Health or Safety. We may use and disclose protected health 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.
13. Organ and Tissue Donations. If you are an organ donor, we may release protected health 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 or transplantation.
14. Military- If you are a member of the armed forces, we may release protected health information about you as required by military command authorities. We may also release protected health information about foreign military personnel to the appropriate foreign military authority.
15. Workers Compensation- We may release protected health information about you for workers’ compensation or similar programs as authorized by state laws. These programs provide benefits for work-related injuries or illness.
16. Public Health Risks- We may disclose protected health information about you for public health activities, to, for example:

  • prevent or control disease, injury or disability;

  • report births and deaths;

  • report child abuse or neglect;

  • report reactions to medications or problems with products;

  • notify people of recalls of products they may be using;

  • notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition as ordered by public health authorities;

  • notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence, if you agree or when required by law.

17. Health Oversight Activities- We may disclose your protected health information to a health oversight agency for activities necessary for the government to monitor the health care system, government programs, and compliance with applicable laws. These oversight activities include, for example, audits, investigations, inspections, medical device reporting and licensure.
18. Lawsuits and Disputes- If you are involved in a lawsuit or a dispute, we may disclose protected health information about you in response to a court or administrative order. We may also disclose protected health 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.
19. Law Enforcement- We may release protected health 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 I-70 Community Hospital; 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.

20. Coroners, Medical Examiners and Funeral Directors- We may release protected health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine cause of death. We may also release protected health information about patients of I-70 Community Hospital to funeral directors as necessary to carry out their duties.
21. National Security and Intelligence Activities- We may release protected health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
22. Protective Services for the President and Others- We may disclose protected health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
23. Inmates- If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release protected health information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the correctional 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.

YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU.
You have the following rights regarding protected health information we maintain about you:

1. Right to Inspect and Copy- You have the right to inspect and request a copy of your protected health information, except as prohibited by law.

To inspect and/or request a copy of your protected health information that may be used to make decisions about you, you must submit your request in writing. If you request a copy of the information, we may charge a fee of 25 cents a page to offset the costs associated with the request.

We may deny your request to inspect and copy in certain circumstances. If you are denied access to protected health information, you may request that the denial be reviewed. Another licensed health care professional chosen by I-70 Community Hospital will review your request and the denial. The person conduction the review will not be the person who denied your request. We will comply with the outcome of the review.

2. Right to Amend- If you feel that protected health 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 I-70 Community Hospital. To request an amendment, your request must be made in a writing that states the reason for the 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 protected health information kept by or for I-70 Community Hospital;
is not part of the information which you would be permitted to inspect and copy; or
is accurate and complete

3. Right to an Accounting of Disclosures- You have the right to request one free accounting every 12 months of the disclosures we made of protected health information about you. To request this list, you must submit your request in writing. Your request must state the time period during which disclosures should be counted. The time period may not be longer than six years and may not include dates before November 15, 2005. Your request should indicate in what form you want the list (for example, on paper, electronically). For additional lists, we may charge you for the costs 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.

4. Right to Request Restrictions- You have the right to request a restriction or limitation on the protected health 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 protected health information we disclose about you to someone who is involved in your care of 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.

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.

To request restrictions, you must make your request in writing. 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.
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.

To request confidential communications, you must make your request in writing. 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.

6. 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.


To obtain a paper copy of this notice, contact:

Geri Fuhrman, Director of Patient Services
I-70 Community Hospital
105 Hospital Drive
Sweet Springs, Missouri 65351
Phone: 660-335-7409
 


CHANGES TO THIS NOTICE
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for protected health 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 I-70 Community Hospital. The notice will contain on the first page, near the top, the effective date. In addition, each time you register at I-70 Community Hospital for treatment or health care services we will make available to you, if you request, a copy of the current notice in effect.

AUTHORIZATION FOR OTHER USES OF PROTECTED HEALTH INFORMATION.
Other uses and disclosures of protected health 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 authorization to use or disclose protected health information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose protected health 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 authorization, and that we are required to retain our records of the care that we provided to you.

COMPLAINTS
If you believe your privacy rights have been violated, you may file a written complaint with I-70 Community Hospital or with the Secretary of the Department of Health and Human Services. To file a complaint with the I-70 Community Hospital, write:

Geri Fuhrman, Director of Patient Services
I-70 Community Hospital
105 Hospital Drive
Sweet Springs, Missouri 65351
Phone: 660-335-7409
 

To file a complaint with the Secretary of the Department of Health and Human Services, contact:

The U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
HHS.Mail@hhs.gov

The complaint to the Secretary must be filed within 180 days of when the complainant knew or should have known that the act or omission complained of occurred. The complaint must be in writing, either on paper or electronically, name the entity that is the subject of the complaint and describe the acts or omissions believed to be in violation of the standards.

You will not be penalized for filing a complaint.

 
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