Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed, as well as how you can get access to this information. Please review it carefully. If you have any questions about this notice, please contact your nurse or case manager who will follow this notice.

This notice describes Siskin Hospital’s practices and that of:

  • Any health care professional authorized to enter information into your hospital chart.
  • All departments and units of the hospital.
  • Any member of a volunteer group we allow to help you while you are in the hospital.
  • All employees, staff and other hospital personnel.
  • All these entities, sites and locations follow the terms of this notice.   In addition, these entities, sites and locations may share medical information with each other for treatment, payment, or hospital operations purposes described in this notice.


Our pledge regarding medical information:

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you.  We create a record of the care and services you receive at the hospital. We need this record 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 hospital, whether made by hospital personnel or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your medical information created in the doctor’s office or clinic.

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


We are required by law to:
  • Make sure that medical information that identifies you is kept private;
  • To give you this notice of our legal duties and privacy practices with respect to medical information about you; and
  • Follow the terms of the notice that is currently in effect.

We are prohibited from the use or disclosure of genetic information for underwriting purposes in accordance with the Genetic Information Nondiscrimination


How we may use and disclose medical information about you:

The following categories describe different ways that we use and disclose medical 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 or give medical information about you to doctors, nurses, therapists, technicians, medical students, students in training or other hospital personnel who are involved in taking care of you at the hospital. Different departments of the hospital may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose medical information about you to people outside the hospital who may be involved in your medical care after you leave the hospital, such as family members, clergy, support groups or others we use to provide services that are part of your care.

For Payment. We may use and disclose your health information to bill and collect payment for the treatment and services provided to you. For example, we may provide portions of your medical information to our billing department and your health plan to get paid for the health care services we provided to you. We may also provide your information to our business associates, such as billing companies, claims processing companies, and others that process our health care claims.

For Health Care Operations.   We may use and disclose medical information about you in order to operate this hospital. For example, we may use your medical information to evaluate the quality of heath care services that you received, to assess your satisfaction with our services or to evaluate the performance of the health care professionals who provided health care services to you. We may also combine the medical information we have with medical information from other hospitals 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 the specific patients are.

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

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.

Health-Related Benefits and Services.  We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.

Marketing and Fundraising Activities.  From time to time, the Hospital sends out mailings, newsletters or brochures about services and programs available at the Hospital. These mailings may also include information about how to support the work of the hospital through charitable gifts. The money raised will be used to expand and improve the services and programs we provide to the community. If you prefer to not be contacted you may opt out by contacting us at 634-1208.

Sale of Protected Health Information (PHI). While Siskin Hospital is not involved in the sale of PHI, we would be required to receive your authorization for any disclosure of your PHI which is related to the sale of PHI. Such authorization will state that the disclosure will result in payment to SHPR.

Hospital Directory/Census.  We may include your name, location in this facility, general condition, and religious affiliation, in our patient directory/census for use by clergy and visitors who ask for you by name. This is so your family, friends and clergy can visit you in the hospital and generally know how you are doing.

Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member or other person that you indicate is involved in your care or the payment for your health care. IN ORDER FOR YOUR FAMILY MEMBER, FRIEND OR OTHER PERSON TO RECEIVE INFORMATION ABOUT YOUR CONDITION, THEY MUST USE THE PRIVACY ID NUMBER GIVEN TO YOU AT ADMISSION.

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, radiology, certain laboratory tests, and transcription service we use for typing medical documents. 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 to bill you or your third-party payer for services rendered. To protect your health information, we require the business associate to appropriately safeguard your information.

Customer Service. As a part of our customer service program, we may use health information about you to contact you by mail or phone after discharge to discuss your opinion of the services provided during your stay at our facility.

Follow-up Contact.  We may use health information about you to contact you by mail or phone following treatment if it is determined you may require additional follow-up.   We may also contact you or your personal physician to find out how you are doing following treatment at Siskin Hospital.

Research.  Under certain circumstances, we may use and disclose medical information about you for research purposes. All research projects are subject to a special approval process, which ensures the privacy of your health information.

As Required by Law.  (Federal, state or local law, judicial or administrative proceedings, or law enforcement)  For example, we make disclosures when a law requires that we report information to government agencies and law enforcement personnel about victims of abuse, neglect, or domestic violence; when dealing with gunshot and other wounds; or when ordered in a judicial or administrative proceeding.

To Avoid Harm.  In order to avoid a serious threat to the health or safety of a person or the public, we may provide medical information to law enforcement personnel or persons able to prevent or lessen such harm.


Special Situations

Organ and Tissue Donation.  We may notify organ procurement organizations to assist them in organ, eye, or tissue donation and transplants, if you are an organ donor.

Specific Government Functions.   We may disclose the medical information of military personnel and veterans in certain situations.  We may also disclose medical information for national security purposes.

Workers’ Compensation.  We may provide your medical information to comply with workers’ compensation laws.

Public Health Activities.   We may disclose medical information about you for these activities that generally include the following:  to prevent or control disease, injury or disability; to report births and deaths; to report abuse/neglect (we will only make this disclosure if you agree or when required or authorized by law); 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.

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 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.

State Specific Requirement. Tennessee has requirements for reporting data, including population-based activities relating to improving health or reducing healthcare costs.

Coroners, Medical Examiners, and Funeral Directors. This may be necessary to determine the cause of death. We may also release medical information about patients of the hospital to funeral directors as necessary to carry out their duties.


You have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy.  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 information that may be used to make decisions about you, you must submit your request in writing to the Medical Records Department. If you request a copy of the information, we will 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 in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed.   Another licensed health care worker chosen in the hospital 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. 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 the information is kept by or for the hospital.

To request an amendment, your request must be made in writing and submitted to the Director of Health Information Services. The Request for Amendment form (Attachment F of policy) may be used to complete this request. In addition, you must provide a reason that supports your request. We will respond within 60 days of receiving 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; is not part of the medical information kept by or for the hospital; is not part of the information which you would be permitted to inspect or copy; or is accurate and complete.

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. Unless otherwise required by law, you have a right to restrict certain health information disclosures to health insurers if you pay full cost of services at the time of your visit.

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 to Medical Records. 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.

All requests will be reviewed for consideration of acceptance, therefore you will not receive an immediate response to your request. Every effort will be made to provide you a response to your request within 30 days.

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 request in writing to Medical Records Department. 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 an Accounting of Disclosures.  You have the right to request an “accounting of disclosures.” This is a list of the individuals and/or institutions to which we have released your private medical information. The list will not include uses or disclosures that you have already consented to, such as those made for treatment, payment, or health care operations, directly to you or your family.

To request this list or accounting of disclosures, you must submit your request in writing to the Medical Records Department. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request will be free. 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.

Right to Breach Notification In the event of any breach of unsecured PHI, Siskin Hospital staff shall fully comply with the HIPAA/HITECH breach notification requirements, including notification to you of any impact that the breach may have had on you and/or your family member(s) and actions Siskin Hospital undertook to minimize any impact the breach may or could have on you.

Right to Get This Notice by E-Mail.  You have the right to a paper copy of this notice. You may ask us to give you a copy at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy. You may obtain a copy of this notice on our website.  Please print this page to serve as a paper copy.

Personal Representative.  Your “personal representative” may exercise the rights listed above on your behalf in making decisions related to health care. If you live in Tennessee and do not have a “personal representative” you may wish to create a legal document called Durable Power of Attorney for Health Care.  This may be extremely beneficial in the unfortunate situation you are unable to make a decision for yourself and wish for someone to act upon your behalf.


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 medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the hospital. 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 hospital for treatment or health care services we will offer you a copy of the current notice in effect.



If you believe your privacy rights have been violated, you may file a complaint with the hospital compliance hotline at 634.1211. To file a written complaint with the hospital, contact:

Privacy Officer
Siskin Hospital for Physical Rehabilitation
One Siskin Plaza
Chattanooga, TN 37403

If you feel we have been unable to resolve your concern you may contact Secretary of the Department of Health and Human Services  at 240.453.2800.

Additionally, if you have a concern about your care that you have brought to Siskin Hospital’s attention and we have not been able to address to your satisfaction, you may contact the Center for Improvement of Healthcare Quality via:
– Website:
– Phone: 1.866.324.5080
– Fax: 805.934.8588
– Mail:
Center for Improvement in Healthcare Quality (CIHQ)
P.O. Box 3620
McKinney, TX 75070
You will not be penalized for filing a complaint.


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.