UnityPoint Health® – Marshalltown Patient Rights

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PATIENT RIGHTS AND RESPONSIBILITIES 2 NOTICE OF PRIVACY POLICIES 11

You are a full partner inin youryour hospitalhospital care.care. 13.14. HaveBe provided an advance with directive, information such which as a livingmeets will the or needs a healthcare of Accounting. You have the right to receive a list of certain How can we use your health information? power of attorney, and to have hospital staff and practitioners who When you you are are well well informed, informed, participate participate in treatment in treatment decisions patients with vision, speech, hearing, language or cognitive disclosures of your health information made by us or our business The law allows the UnityPoint Health ACE to use or share your provide care in the hospital comply with theses directives. These anddecisions communicate and communicate openly with your openly physician with your and otherphysician health impairments. associates. You must state a time period for your request, which health information for routine activities without requiring your professionals, you help make your care as effective as possible. documents express your choices about your future care or name may not be longer than six years. The first list in any 12-month permission, such as: and other health professionals, you help make your care as 14. Expect unrestricted access to communication. If visitors, mail, someone to make healthcare decisions if you are unable. If you period will be provided to you for free; you may be charged a fee effective as possible. telephone calls, or other forms of communication are restricted • For treatment We respect your personal preferences and values. UnityPoint have a written advance directive, you should provide a copy to the for each subsequent list you request within the same 12-month as a component of your care, you will be included in any such HealthWe respect - Allen your Hospital personal promotes preferences the rights, and interests values. and UnityPoint well- hospital, your family and your doctor. You may review and revise period. Your right to an accounting of disclosures does not include • For payment being of our patients. It is our policy that these rights shall be decision. Health – Marshalltown promotes the rights, interests and your advance directive. The existence or lack of an advance disclosures for treatment, payment or healthcare operations and • To run the hospital or physician group respected,well-being and of ourno patient patients. shall It be is requiredour policy to waivethat these these rightsrights as 15.directive Have does the hospital not determine support an your individual’s right to access access protective to care, and certain other types of disclosures, for example, as part of a facility • For appointment reminders and communications ashall condition be respected, of treatment. and no patient shall be required to waive treatmentadvocacy or services. services by providing a list of community resources. directory or disclosure in accordance with your authorization. these rights as a condition of treatment. Requests must be in writing. You may contact the Privacy Officer The law also allows the UnityPoint Health ACE to use and share As a patient, parent or legally responsible representative The15. Refuse Right medical to Information care, treatment or services to the extent to obtain a form to request an accounting of disclosures. Health information without your permission for other limited of a patient, you have the right to: permitted by law and regulation and to be informed of the As a patient, parent, or legally responsible representative 16. Be informed in writing of your rights before patient care is reasons, including: 1.of Be a patient,informed inyou writing have of the your right rights to: before patient care is medicalfurnished consequences or discontinued of such whenever refusal. When possible. you are not legally Confidential Communications. You have the right to request furnished or discontinued whenever possible. responsible, your surrogate decision-maker, as allowed by law, has that we communicate with you about your health information in a • Public health activities 17. Expect that your family member (or representative) AND The Right to Respect the right to refuse care, treatment or services on your behalf. different way or at a different place. We will agree to your request primary care physician, as identified by you, will be notified • Some research activities 2.1. ReceiveBe treated effective kindly communication. and respectfully byWhen all hospitalwritten information personnel is if it is reasonable and specifies the alternate means or location to 16. Accesspromptly to receiveby hospital treatment, staff of care your or inpatient services withinadmission. the Health and safety reasons provided,(including it is appropriate volunteers toand your students), age, understanding other patients, and visitors, language contact you. • appropriate to the populations we serve. capability and mission of Allen Hospital, in compliance with law, and personal representatives or family members. 18. Be informed of the hospital rules and regulations applicable to • Organ and tissue donation requests regulationyour conduct and payment as a patient. policies. Notice in the Case of Breach. You have the right to receive 3.2. HaveKnow language that UnityPoint interpreters Health available – Marshalltown at no cost to will you. not If you • Workers’ compensation requests notice of an access, acquisition, use or disclosure of your health havediscriminate vision, speech, or permithearing, discrimination language or cognitive based on impairments, color, national 19.17. RequestReceive transfer information of your about care rights to another as a Medicare physician beneficiary or facility. at information that is not permitted by HIPAA, if such access, • Law enforcement requests the hospitalorigin, sex, will age, address race, those ethnicity, communication religion, culture, needs. language, admission. acquisition, use or disclosure compromises the security or privacy physical or mental disability, socio-economic status, sexual 18. Receive medical evaluation, service and/or referral indicated • Some fundraising activities 20. Be informed of your health status. of your PHI (we refer to this as a breach). We will provide such 4. Beorientation, treated kindly or gender and respectfully identity expression. by all hospital personnel. by the urgency of your situation. When medically permissible, you Uses and sharing permitted or required by law notice to you without unreasonable delay but in no case later than • 21.may Receivebe transferred complete to anotherand current facility information only after concerning having received 5.3. ReceiveBe free complete from abuse, and harassment,current information neglect, concerningexploitation, your aversive 60 days after we discover the breach. completeyour diagnosis, information treatment, and explanation and prognosis concerning in terms the you need can for What Activities Require Your Written Permission? diagnosis,therapy, treatment corporal and punishment, prognosis orin denialterms youof basic can needs.understand. and understand.alternative to When such ait transfer. is not medically The facility advisable to which to give you suchwill be If the UnityPoint Health ACE needs to use or disclose your health When it is not medically advisable to give such information, it How to Exercise These Rights. All requests to exercise these 4. Be treated in an environment that preserves dignity and transferredinformation, must itfirst should accept be madethe transfer. available to an appropriate information for other purposes not described in this frequently should be made available to an appropriate person on your behalf. rights must be in writing. We will follow written polices to handle supports your positive self-image. person on your behalf. asked questions guide or the attached full Notice of Privacy 19. Be involved in decisions subject to internal or external review requests and notify you of our decision or actions and your rights. Practices, we must ask for your written authorization. 6.5. ConsultReceive with care a specialistin a safe and of your secure choosing environment at your for request you and and your 22.that Knowresult thein denial name, of identity, care, treatment, and professional services status or payment of the based Contact the Privacy Officer at 319-235-3913 located at expense if a referral is not deemed medically necessary by your personal property. uponphysician your assessed or other medical practitioners needs. providing care, services, and 1825 Logan Ave., Waterloo, IA 50703 for more information or to What Activities Do You Have a Right to Object to? attending physician. treatment to you at the time of service. obtain request forms. In many circumstances, you may have the right to object before we 6. Have your cultural, psychosocial, spiritual and personal values, 20. Receive care and treatment that maintains your personal do the following: 7. Bebeliefs, given an and explanation preferences of respected.any proposed procedure or treatment. 23.privacy Know and the dignity. name Discussions of the physician about or your other care, practitioner examination who oris Complaints. If you have concerns about any of our privacy practices The explanation should include a description of the nature and primarily responsible for your care, treatment, and services 7. Exercise cultural and spiritual beliefs that do not interfere treatment are confidential and should be conducted discretely. or believe that your privacy rights have been violated, you may file • Share information with your family members, friends or purpose of the treatment or procedure; the known risks or serious within 24 hours after admission. with the well-being of others. Certain cultural and spiritual You have the right to exclude those persons not directly involved a complaint with the UnityPoint Health ACE using the contact others involved in your care side effects; and treatment alternatives. information at the end of this Notice. You may also submit a written beliefs may nevertheless interfere with the planned course 24.in the Access care. Ifinformation you desire containedto have private in your telephone medical recordsconversations, within a • List your name, room number and condition in a directory you will have access to private space and telephones appropriate complaint to the U.S. Department of Health and Human Services. You 8. Knowof your the medicalname, identity therapy. and You professional may exercise status your of cultural the physician and reasonable timeframe. See UnityPoint Health System policies: available to hospital visitors, as well as list your religion in a to your needs. will not be penalized or retaliated against for filing a complaint. or otherspiritual practitioners beliefs and providing take actions care, asservices are legally and treatmentrecognized to and you Release of Protected Health Information-No Authorization directory available to clergy members permissible in the State of Iowa. Required, Release of Protected Health Information- at the time of service. 21. Be treated in an environment that preserves dignity and Authorization Required, and Release of Protected Health Who will follow these privacy practices? 8. Receive safe and effective care, treatment, and services supports your positive self-image. The healthcare organizations that are a part of UnityPoint Health 9. Know the name of the physician or other practitioner who is Information-Substance Abuse/Mental Health and HIV/AIDS. regardless of your ability to pay. have collectively formed an Affiliated Covered Entity or “ACE” primarily responsible for your care, treatment and services within 25.22. ExpectAccess, that request all communications amendment to, and and clinical receive records an accounting pertaining of under the HIPAA regulations for purposes of HIPAA compliance. 249. hoursBe free after from admission. restraints or seclusion of any form that are not to yourdisclosure care will regarding be treated health confidentially. and clinical services information as medically necessary or are used as a means of coercion, A full list of organizations in the UnityPoint Health ACE, called permitted by law. “Affiliates” are listed in Attachment A to this Notice. Our rules 10. Expectdiscipline, that convenience,a family member or retaliation (or representative) by staff. and physician 23. Access, request amendment to and receive an accounting of to protect your privacy will be followed by all workforce members will be notified promptly of your admission to the hospital. 26.disclosure Examine regarding your bill health and receive and clinical an explanation services information of the charges as The Right to Access of the site where you are being treated, as well as physicians and permittedregardless by law. of the source of payment for your care within a 11. Participate in developing, approving and implementing your 10. Receive access to treatment, care, or services within the reasonable period of time following receipt of a request. other healthcare practitioners with permission to provide services plan capability,of care. capacity, and mission of UnityPoint Health – 24. Access information contained in your medical records within a at our sites who are independent of any UnityPoint Health Affiliate Thereasonable Right timeto Receive frame (see Visitors release of information policies). (together called “the UnityPoint Health ACE” in this Notice). 12. MakeMarshalltown, informed decisionsin compliance and be with involved law, regulations, in resolving and concerns aboutpayment your care, policies. treatment and services. With your permission 27. Be informed of your visitation rights, including any clinical 25. Haverestrictions your cultural, or limitations psychosocial, on such spiritual rights. and personal values, What health information is covered under this notice? and11. asReceive appropriate effective by law, communication. your family will When be involved written informationin care, beliefs and preferences respected. This Notice covers health information at the UnityPoint Health treatmentis provided, and service it is appropriate decisions. to your age, understanding and 28. Be informed of the right, subject to your consent, to receive ACE that may be written (such as a hard copy medical record language appropriate to the populations we serve. the visitors you designate, including but not limited to: spouse, file), spoken (such as physicians discussing treatment options), or 13. Have a surrogate decision-maker, as allowed by law, identified when domestic partner (including same sex domestic partner), 12. Have language interpreters available at no cost to you. electronic (such as billing records kept on a computer). you cannot make decisions about your care, treatment and services. another family member or friend, and your right to withdraw or deny such consent at any time. NOTICE OF PRIVACY POLICIES 10 PATIENT RIGHTS AND RESPONSIBILITIES 3

Business Associates. Some of the activities described above Your Rights 26.29. ExerciseKnow that cultural UnityPoint and spiritual Health beliefs– Marshalltown that do not is committedinterfere with IFMCwith these directives. These documents express your choices are performed through contracts with outside vendors called Access to Health Information. You may inspect and copy the well-beingto ensuring of that others. all visitors Certain enjoy cultural full andand equalspiritual visitation beliefs may 6000about Westown your future Parkway care or name someone to make healthcare business associates. We will disclose your health information to much of the health information we maintain about you, with some neverthelessprivileges interfere consistent with with the your planned preferences. course of your medical Westdecisions Des Moines, if you are IA unable.50266 If you have a written advanced our business associates and allow them to create, use and disclose therapy. You may exercise your cultural and spiritual beliefs and 515-223-2900directive, you should provide a copy to the hospital, your family, exceptions. If we maintain the information electronically and The Right to Medical Treatment and Decision Making your health information to perform their services for us. For you ask for an electronic copy, we will provide the information to take actions in accordance therein as are legally recognized and and your doctor. If you have an IPOST, you should bring it example, we may disclose your health information to an outside you in the form and format you requested, assuming it is readily permissible30. Participate in the in developing,State of Iowa. approving, and implementing your If youwith have you a complaintto the hospital about upon your your care, admission. you may also You notify:may review billing company who assists us in billing insurance companies. We producible. If we cannot readily produce the record in the form plan of care. The andJoint revise Commission your advanced (healthcare directive accreditation at any time. organization) The existence 27. Know if your care involves any experimental methods of at this address: require business associates to appropriately safeguard the privacy and format you request, we will produce it another readable 31. Make informed decisions and be involved in resolving concerns or lack of an advanced directive does not determine an treatment, and if so, you have the right to consent or refuse of your information. electronic form we agree to. We may charge a cost-based fee for about your care, treatment and services. With your permission Theindividual’s Joint Commission access to care, treatment, or services. to participate. This will not compromise your access to care, producing copies or, if you request one, a summary. If you direct and as appropriate by law, your family will be involved in the One Renaissance Boulevard Organized Healthcare Arrangement. We offer clinically integrated treatment and services. 44. Be informed about the outcomes of your care, treatment, us to transmit your health information to another person, we will care, treatment, and service decisions. Oakbrookand services Terrace, including IL 60181 unanticipated outcomes that you must care settings where patients receive care from Affiliates in the do so, provided your signed, written direction clearly designates 630-792-5000 UnityPoint Health ACE and from independent doctors and other 28.32. BeBe informed given an explanationby the practitioner of any proposedof any continuing procedure healthcare or be knowledgeable about to participate in current and future the recipient and location for delivery. We may charge a fee for the requirements following discharge. [email protected] affecting your care, treatment, and services. practitioners who provide care to patients at facilities in the costs of copying, mailing and other supplies or work associated treatment. The explanation should include a description of the UnityPoint Health ACE (collectively called “practitioners”). The nature and purpose of the treatment or procedure, the known with your request. We will respond to your requests to exercise 29. Examine your bill and receive an explanation of the charges 45.34. BeKnow free that from the restraints hospital or informs seclusion you of or any your form surrogate that are decision not Affiliates and these practitioners need to share health information risks or serious side effects, and treatment alternatives. any of the above rights on a timely basis in accordance with our regardless of the source of payment for your care within a medicallymaker necessary of unanticipated or are used outcomes as a means of your of care,coercion, treatment, discipline, and freely to provide care to patients and to conduct Affiliates’ policies and as required by law. reasonable33. Know that period UnityPoint of time followingHealth – Marshalltown’sreceipt of a request. informed convenienceservices that or retaliation relate to sentinel by staff. events. healthcare operations. Therefore, the Affiliates and the practitioners consent policy includes what care, treatment, and services have agreed to follow uniform information practices when using The35. Receive Right toinformation Privacy about rights as a Medicare beneficiary Request for Restrictions. You have the right to request 30. Berequire informed informed of the consent, hospital exceptions rules and regulations to informed applicable consent, to or disclosing health information related to inpatient or outpatient 46.at admission. Receive care and treatment that maintains your personal a restriction or limitation on the health information we use yourwhen conduct a surrogate as a patient. decision maker can give informed consent, hospital services. This arrangement is called an “Organized privacy and dignity. Discussions about your care, examination, or disclose about you for treatment, payment or healthcare and all the elements that comprise informed consent. 36. Receive care in a safe and secure environment for you and Healthcare Arrangement” and only covers information practices 31. Use the Allen Hospital grievance (complaint) resolution process or treatment are confidential and should be conducted operations or to persons involved in your care or payment for your properties. for services rendered through the Affiliates. It does not cover the your care. We are not required to agree to your request, with one for34. submittingReceive appropriate a written or assessment verbal grievance and management to the Patient of Advocate, pain. discretely. You have the right to exclude those persons not information practices of the practitioners in their offices or at your caregivers, your healthcare practitioners or Administration. directly involved in your care. If you desire to have private exception explained in the next paragraph, but we will let you know 35. Receive medical evaluation, service, and/or referral indicated 37. Be free from all forms of abuse, neglect, exploitation or harassment. other care settings. It does not alter the independent status of the You may freely voice complaints and recommend changes without telephone conversations, you will have access to private space whether we have agreed to your request. by the urgency of your situation. When medically permissible, Affiliates and the practitioners or make them jointly responsible being subject to coercion, discrimination, reprisal or unreasonable and telephones appropriate to your needs. you may be transferred to another facility only after having 38. Receive appropriate assessment and management of pain. for the clinical services provided by them. The Affiliate(s) are not We are required to agree to your request that we not disclose interruption of care, treatment and services. If you submit a received complete information and explanation concerning the 47. Expect that all communications and clinical records pertaining responsible for (1) the negligence (or mistakes) of the independent certain health information to your health plan for payment or complaint or grievance, it will be investigated. Action will be taken to 39. Expect unrestricted access to communication. If visitors, mail, need for an alternative to such a transfer. The facility to which to your care will be treated confidentially. practitioners providing care at the Affiliate(s) or (2) any violations of healthcare operations purposes if (1) you pay out-of-pocket in full resolve the concern either verbally or in writing when appropriate. telephone calls, or other forms of communication are restricted as a you will be transferred must first accept the transfer. component of your care, you will be included in any such decision. your privacy rights by the independent practitioners. for all expenses related to that service either at the time of service • The telephone number for Allen Patient Advocacy is The Right to File a Complaint 36. Be informed by the practitioner of any continuing healthcare or within timeframes specified by our written policies and (2) the 319-235-3573. 48. Use the UnityPoint Health – Marshalltown grievance Uses and Disclosures Requiring Your Authorization. requirements following discharge. 40. Be informed of your health status. disclosure is not otherwise required by law. Such a restriction will (complaint) resolution process for submitting a written or There are many uses and disclosures we will make only with your only apply to records that relate solely to the service for which • The telephone number for Allen Administration is 37. Refuse medical care, treatment, or services to the extent 41. Haveverbal the grievance hospital to support the Patient your rightAdvocate to access (319-235-3567), protective and your written authorization. These include: you have paid in full. If we later receive an authorization from you 319-235-3987. permitted by law and regulations and be informed of the advocacycaregivers, services your by healthcare providing practitioners,a list of community or administration. resources. dated after the date of your requested restriction which authorizes • To submit a concern online, visit unitypoint.org and click Contact. We will medical consequences of such refusal. When you are not You may freely voice complaints and recommend changes Uses and Disclosures Not Described Above. us to disclose all of your records to your health plan, we will 42. Be informed about the outcomes of your care, treatment obtain your authorization for uses and disclosures of your health • Tolegally mail us responsible, a concern, youruse this surrogate address: decision maker, as allowed without being subject to coercion, discrimination, reprisal, or assume you have withdrawn your request for restriction. and services including unanticipated outcomes that you must be information that are not described in the Notice above. Allenby law, Hospital has the right to refuse care, treatment, or services on unreasonable interruption of care, treatment, and services. If knowledgeable about to participate in current and future decisions Several different covered entities listed at the start of this Notice Patientyour behalf. Advocacy you submit a complaint or grievance, it will be investigated. Psychotherapy Note. These are notes made by a mental health 1825 Logan Avenue affectingAction your will becare, taken treatment to resolve and the services. concern either verbally or in use this Notice, including the entities listed in Attachment A 38. Request transfer of your care to another physician or facility. professional documenting conversations during private counseling writing when appropriate. that are a single covered entity known as the UnityPoint Health Waterloo, IA 50703 43. Safe and effective care, treatment and services regardless of sessions or in joint or group therapy. Many uses or disclosures of Affiliated Covered Entity (or UnityPoint Health ACE”), as well 39. Consult with a specialist of your choosing at your request and 32. Receive a written response to your grievance from the hospital 49.the patient’sReceive a ability written to responsepay. to your grievance from the hospital. psychotherapy notes require your authorization. as physicians and other healthcare practitioners with permission expense if a referral is not deemed medically necessary by your within seven (7) calendar days. See Patient and Family Complaints/Grievances policy for to provide services at our sites who are independent of any attending physician. 44. Know which patient care areas have limited visitation and if Marketing. We will not use or disclose your protected health timeframe. UnityPoint Health Affiliate. You must make a separate request to 40. Be involved in decisions subject to internal or external review admitted to one of these areas, to have these limitations discussed information for marketing purposes without your authorization. 33. Refer complaints or grievances regarding quality of care, 50. Refer concerns or grievances regarding quality of care, each covered entity from whom you will receive services that are that result in denial of care, treatment, services, or payment with you (or support person as appropriate) at the time of Moreover, if we will receive any financial remuneration from a third premature discharge or beneficiary complaints to: premature discharge, or beneficiary complaints to appropriate involved in your request for any type of restriction. Contact the based upon your assessed medical needs. admission. (Areas with limitations: NICU, Mental Health, PACU, party in connection with marketing, we will tell you that in the organization. UnityPoint Health ACE or Affiliate Privacy Officer at the contact Iowa Department of Inspections and Appeals ED and OB). authorization form. 41.Health Know Facilities if your care Division involves any experimental methods of information listed below if you have questions regarding which a. Iowa Department of Inspections and Appeals at Lucastreatment, State Office and if so, Building you have the right to consent to or refuse 45. Receive the visitors you designate. Any specific requests by We will not sell your protected health information to third providers will be involved in your care. 515-281-4115 or at Health Facilities Division, Sale. Desto Moines,participate IA 50319which will not compromise your access to care, patients will be documented in the nurses’ notes. parties without your authorization. Any such authorization will Lucas State Office Building, Des Moines, Iowa 50319. Amendment. You may request that we amend certain health Tolltreatment, free 877-686-0027 and services. state that we will receive remuneration in the transaction. 46. Knowb. Keystone that Allen Peer Hospital Review does Organization not restrict, (KEPRO) limit or deny information that we keep in your records if you believe that it is Medicare42. Have patientsa surrogate may decision-maker, also refer their asconcerns identified to the by law,Iowa to make visitation (Medicare privileges patients) on the basis at 855-408-8557 of race, color, national or at origin, If you provide authorization for the disclosure of your health incorrect or incomplete. We may require you to give a reason to Foundationdecisions for about Medical your Care care, (IFMC), treatment, the Medicareand services. quality religion, 5201sex, gender West Kennedy identity, Boulevard,sexual orientation Suite 900, or disability. information, you may revoke it at any time by giving us notice in support your request. We are not required to make all requested Tampa, Florida 33609, Attention: Beneficiary Complaints. improvement43. Have an advanced organization directive, for Iowa, such at as this a livingaddress: will, a healthcare accordance with our authorization policy and the instructions in amendments, but will give each request careful consideration. 47. Know that Allen Hospital is committed to ensuring that all power of attorney, or Iowa Physician Orders for Scope of our authorization form. Your revocation will not be effective for If we deny your request, we will provide you with a written visitors enjoy full and equal visitation privileges consistent with Treatment (IPOST) and have hospital team members and uses and disclosures made in reliance on your prior authorization. explanation of the reasons and your rights. patient preferences. practitioners who provide your care in the hospital comply PATIENT RIGHTS AND RESPONSIBILITIES 4

AsAs a patient,patient, youyou havehave the responsibilityresponsibility: ConfidentialityKEPRO 1. To provide accurate and complete information about present 5201 West Kennedy Boulevard, Suite 900 1. To provide accurate and complete information about present Your right to confidentiality is included in your rights as a patient. complaints, past illnesses, hospitalizations, medications and other Tampa, Florida 33609 complaints, past illnesses, hospitalizations, medications, and All UnityPoint Health – Marshalltown employees are bound to matters relating to your health, including advance directives; and Attention: Beneficiary Complaints other matters relating to your health, including advanced confidentiality by hospital policy and professional and personal ethics. to report perceived risks in your care, unexpected changes in your 855-843-4776 directives, reporting perceived risks in your care, unexpected Only persons with legitimate interests, who must utilize information condition and whether you clearly comprehend a contemplated changes in your condition, and whether you clearly found in clinical records or communications in order to carry out their course of action and what is expected. comprehend a contemplated course of action and what is dutiesConfi dandentiali responsibilitiesty to the patient and the hospital, may have expected. accessYour right to this to c information.onfidentiality In is addition, included patient in your information rights as a p toat iwhichent. 2. To follow the treatment plan recommended by the practitioner All Allen Associates are bound to confidentiality by hospital employees have access either formally or informally shall not be 2.primarily To follow resp othensible treatment for you planr car e.recommended This may inc lbyud thee fo practitionerllowing the policy and professional and personal ethics. Communications, disclosed or discussed outside the realm of professional responsibility. instruprimarilyctions o responsiblef nurses and for ot hyourer h ealthcare. c Thisare p mayrofe sincludesionals followingas they such as written reports, documents, records, computer printouts, implemthee instructionsnt the practiti ofo nursesner’s o andrder others and healthcareenforce the professionals applicable Privacyschedules or other written information, is considered confidential. hospitalas they rules implement and regu lationthe practitioner’ss. orders and enforce the Only persons with legitimate interests, who must utilize applicable hospital rules and regulations. Weinformatio are requiredn foun byd ifederaln clinica lawl re toco maintainrds or co mthem uprivacynicatio ofns yourin or dmedicaler 3. For your actions if you refuse treatment or if you do not follow information and give you our Notice of Privacy Practice that describes 3. For your actions if you refuse treatment or if you do not follow to carry out their duties and responsibilities to the patient and the the practitioner’s instructions. our privacy practices, our legal duties and your rights concerning your the practitioner’s instructions. hospital, may have access to this information. In addition, patient medicalinformation information. to which This Associ Noticeates hisa includedve access in e ithisther brochure formally oandr 4. ToTo as assuresure tha thatt th thee fi nafinancialncial obligation obligationss of yofo uyourr ca rcaree ar eare fulfill fulfilleded isin falsoormall availabley shall inno at separatebe disclo sebrochured or dis cinu seithersed o uEnglishtside t hore Spanishrealm of as prasomp promptlytly as p oasss possible.ible. andprof willessi obenal offered responsibili to youty .at the time you are admitted, or prior to 5. To follow hospital rules and regulations affecting patient care receiving outpatient care. and candond conduct.uct. Amo ng these are prohibition of the use of any Privacy Confidential Status 6.tob aTocco be p rconsiderateoducts or al cofoh theoli crights beve ofrag otheres on patientsthe premi andses hospital of the We are required by federal law to maintain the privacy of your hospitalpersonnel, and hospital and for visitor assisting policie in thes. control of noise, smoking, Confidentialitymedical information about a nyourd gi vhealthe you oustatusr No isti cimportant.e of Priva cYouy P ractmay icwante and the number of visitors in your room. tothat designate describes a familyour pr icontactvacy pr atoct provideices, our updates legal du totie others.s and y oWeur will 6. To be considerate of the rights of other patients and hospital striverights toco protectncernin gyour you privacyr medical during infor yourmati ostay.n. T hPatientsis Notic whoe is wish to 7.pe rsonTo naskel, andquestions for as swhenisting you in th doe cnotont understandrol of noise, whatsmoking you ahavend have complete privacy and avoid all outside contacts may request numberbeen o ftold visito aboutrs in youryour care room or. what you are expected to do. totim bee yconfidential.ou are admitted, With o rthis pri olevelr to rofec eivconfidentiality,ing outpatien tour ca rstaffe. will 8. To make your concerns, complaints, or grievances related to neither confirm nor deny a patient’s presence at the hospital. Room 7. To ask questions when you do not understand what you have patient care known to your caregiver, a patient representative, andDo Ntelephoneot Anno numbersunce St willatu nots be disclosed. Flowers, mail or other been told about your care or what you are expected to do. or other UnityPoint Health – Marshalltown official. parcelsConfide willntiality be returned about y otour the heal sender.th status is important. Information can only be given to immediate family. You may want to designate Complaints a family contact to provide updates to others. We will strive to ComplaintsIt is the goal of Allen Hospital that associates closest to the issue protect your privacy during your stay. Patients who wish to have Weadd believeress complaints that these an rightsd con candern sresponsibilities immediately. P contributeatients ha vtoe more complete privacy and avoid all outside contacts may request Do effectivethe right t opatient voice ccareomplain and tgreaters or co nsatisfaction.cerns to th oIfs eyou immedi do notat ebelievely theseinvolv rightsed. Ho andwev responsibilitieser, if you do not are feel being your adequately complaint oupheld,r conce pleasern will neither confirm nor deny a patient’s presence at the hospital. talkis bei withng ad yourdre nursessed adequately or contact other in Patient a time lyAdvocate. manner, or if you are Room and telephone numbers will not be disclosed. Flowers, mail uncomfortable, please call or submit your issue in writing: Patient Advocate or other parcels will be returned to the sender. PrUnityesiden Pointt an dHealth CEO – Marshalltown 3U Snit 4thyPo Avenueint Health-Waterloo Marshalltown,1825 Logan Av enIAu 50158e (641)Waterl 754-5287oo, IA 50703 319-235-3987 or 3987 on your room phone President and CEO AllenUnity H oPointspital Health suppo r–ts Marshalltown the patient’s right to access protective se3rv Sic 4thes, i Avenuencluding but not limited to guardianship, advocacy and childMarshalltown, or adult protect IA 50158ive services. You have the right to access sta(641)te client 754-5145 advocacy groups and to file a complaint if you have a concern about patient abuse, neglect or misappropriation of your UnityPointproperty in Healthour facili – tMarshalltowny. The followi supportsng agencies the a patient’sre available right to toas siaccessst you protective: services, including but not limited to guardianship, advocacy and child or adult protective services. You have the right to access state client advocacy groups and to file a complaintThe Join ift Commyou haveissi ao concernn about patient abuse, neglect or misappropriationOne Renaissan cofe yourBlvd .property in our facility. Oakbrook Terrace, Illinois 60181 800-994-6610 NOTICE OF PRIVACY POLICIES 8 ADVANCE DIRECTIVES 5

Appointment Reminders. We may contact you as a reminder that Public Health Activities. We may disclose health information As ana UnityPoint Allen patient, Health you - shouldMarshalltown have been patient, provided you should with have In addition, medication or medical procedures necessary to you have an appointment for treatment or medical services. about you for public health activities. These activities may include informationbeen provided that with will information help you make that decisionswill hp you on make medical decisions care provide comfort or to ease pain are not life sustaining, and will not disclosures: youon medical might need care inyou the might future. need Competent in the future. adults Competent have the right to be withheld under a Living Will. It should be noted that the Iowa Treatment Alternatives. We may contact you to provide adults have the right to refuse or accept medical treatment • To a public health authority authorized by law to collect or refuse or accept medical treatment after being informed of the General Assembly made changes to the Living Will Law in 1992, information about treatment alternatives or other health-related proceduresafter being informed and risks. of the procedures and risks. so if you completed a Living Will before April 23, 1992, your Living benefits and services that may be of interest to you. receive such information for the purpose of preventing or controlling disease, injury or disability Will may not allow for withdrawal or withholding of intravenous However, there is growing concern over how medical care feeding or feeding tubes. It may not apply if you are not about to Fundraising. We may contact you by writing, phone or other • To appropriate authorities authorized to receive reports of decisions will be made when patients are unable to make decisions die but are in a permanent state of unconsciousness with no likely means as part of a fundraising effort for the purpose of raising child abuse and neglect for themselves. Today, medical technology presents us with a hope of future recovery. It will only apply in those situations if you money for one or more of our organizations listed in Appendix number of treatments that prolong life. Some people do not wish specifically stated it should. If you did not specify those cases, you A, and you will have the right to opt out of receiving such • To FDA-regulated entities for purposes of monitoring or such treatment, while others wish to take advantage of every may want to complete a new Living Will. You should consult your communications with each solicitation. Please note that we will reporting the quality, safety or effectiveness of treatment available. attorney for advice. promptly process your request to be removed from our fundraising FDA-regulated products list, and we will honor your request unless we have already sent a • To notify a person who may have been exposed to a disease Often decisions must be made when the patient is no longer able Durable Power of Attorney for Healthcare is a document through communication prior to receiving notice of your election to opt or may be at risk for contracting or spreading a disease to state his or her wishes. which you name another person – known as your attorney-in-fact or out. We may also use and we may disclose to a business associate or condition agent – to make healthcare decisions for you if you become unable. A growing number of people are stating their healthcare choices in or to a foundation related to the UnityPoint Health ACE or one This person is required to make those decisions according to your • With parent or guardian permission, to send proof of writing while they are still able to make these decisions. These legal of its Affiliates certain health information about you, such as document or other directions you provide. If your wishes are not required immunization(s) to a school documents are called Advance Directives, more commonly known your name, address, phone number, email information, dates known, your agent shall make decisions in your best interest. you received treatment or services, treating physician, outcome Abuse, Neglect or Domestic Violence. We may notify the as a Living Will and Durable Power of Attorney for Healthcare. information, and department of service (for example, cardiology appropriate government authority if we believe an individual has You should talk to your physician about the effects of withholding The person you name in a Durable Power of Attorney for or orthopedics), so that we or they may contact you to raise been the victim of abuse, neglect or domestic violence. Unless or withdrawing different treatments. It is also a good idea to Healthcare should be someone you trust and who agrees to be money on our behalf. The money raised will be used to expand and such disclosure is required by law (for example, to report a discuss your decision with your family. While it is not necessary to your agent. The law does not allow this person to be your doctor, improve the services and programs we provide the community. You particular type of injury), we will only make this disclosure if you consult your attorney for your Advance Directive to be a legally nurse or other person providing healthcare to you on the date you are free to opt out of fundraising solicitation, and your decision will agree or in other limited circumstances when such disclosure is binding document, it is often helpful. Let your nurse know if you sign the document; or any employee of the doctor, nurse or any have no impact on your treatment or payment for services by any authorized by law. need assistance with Advance Directives while you are here. An hospital or healthcare facility providing care to you, unless that of the entities covered by this Notice. Advance Directive is a document stating your healthcare choices employee is a close relative. Health Oversight Activities. We may disclose health information or naming someone to make those choices for you if you become Facility Directory. While you are an inpatient at any UnityPoint to a health oversight agency for activities authorized by law. These unable to do so. Your agent can make any decision you can make regarding Health hospital, your name, location in the facility, general oversight activities include, for example, audits, investigations, treatment of your physical or mental condition, including condition (e.g., fair, serious, etc.) and religious affiliation may be inspections and licensure. These activities are necessary for Iowa law provides two types of Advance Directives: withdrawal of intravenous feeding or feeding tubes. In all cases, included in a facility directory. This information may be provided to the government to monitor the healthcare system, government 1) The Declaration Relating to Use of Life-Sustaining your agent must act according to your wishes, and if you wish, members of the clergy and, except for religious affiliation, to other programs and compliance with civil rights laws. Procedures, known as a Living Will you may limit your agent’s scope of authority. It is important to people who ask for you by name. You have the right to request that discuss your wishes with the person who will be your agent, and your name not be included in the directory. We will not include Legal Proceedings. If you are involved in a lawsuit or a dispute, we 2) The Durable Power of Attorney for Healthcare you may also state them on the Durable Power of Attorney form. your information in the facility directory if you object or if we are may disclose health information about you in response to a court It is important to know that healthcare decisions can be made on It is advisable to name an alternate agent in case the person you prohibited by state or federal law. or administrative order. We may also disclose health information your behalf without an Advance Directive. Others will make these appoint becomes unable or unwilling to act on your behalf. about you in response to a subpoena, discovery request or other decisions, in consultation with your physician, and these decision Family, Friends or Others. We may disclose your location or lawful process by someone else involved in the dispute, but only if makers should be guided by your intentions. However, you will A Living Will is a directive to your physician; while Durable Power general condition to a family member, your personal representative reasonable efforts have been made to notify you of the request or to have greater assurance that your wishes will be carried out if you of Attorney for Healthcare lets you name an agent that will direct or another person identified by you. If any of these individuals are obtain an order from the court protecting the information requested. have an Advance Directive. the physician. A Living Will applies only if it is your intention involved in your care or payment for care, we may also disclose to have life-sustaining procedures withheld or withdrawn, and such health information as is directly relevant to their involvement. A Living Will is a document directing your physician that certain you are in a terminal condition. Durable Power lets you specify We will only release this information if you agree, are given life-sustaining procedures should be withheld or withdrawn if you the healthcare you want or don’t want, and its application is not the opportunity to object and do not, or if in our professional are in a terminal condition and unable to decide for yourself. A restricted to terminal conditions or decisions about life-sustaining judgment, it would be in your best interest to allow the person terminal condition is an irreversible condition that, without life- procedures. However, both documents apply only when you are to receive the information or act on your behalf. For example, we sustaining procedures, will result in death in a relatively short time unable to make your own decisions. may allow a family member to pick up your prescriptions, medical or in a state of permanent unconsciousness from which there is supplies or X-rays. In addition, if you are unavailable, incapacitated no likely recovery. The determination of a terminal condition must If you are uncertain about which documents are best for you, or in an emergency situation, we may disclose limited information be made by the attending physician following consultation with consult your physician or attorney for guidance. UnityPoint Health to these persons if we determine in our professional judgment that another physician. A life-sustaining procedure is any mechanical or - MarshalltownAllen Hospital ensures ensures that that the the wishes wishes of of the the patients patients and and their their we believe it is in your best interest. We may also disclose your artificial means which sustains, restores or supplants a vital body families or designated representatives are followed whenever information to an entity assisting in disaster relief efforts so that function and which would only prolong the dying process for a possible, in the hospital’s capacity or to the extent permitted by law. your family or individual responsible for your care may be notified terminal patient. A mechanical respirator is an example. of your location and condition. A Living Will takes effect only when you have a terminal condition Required by Law. We will use and disclose your information as and are unable to make decisions. Iowa’s Living Will Law does not required by federal, state or local law, such as to report child or permit withholding or withdrawing nutrition or hydration (food or dependent adult abuse. water) unless they are provided intravenously or by a feeding tube. ADVANCE DIRECTIVES 6

Iowa Physician Orders for Scope of Treatment (IPOST) In the last stages of illness, health decisions can be complicated The Iowa Physician Orders for Scope of Treatment, known as IPOST, is a double-sided, one-page document, salmon in color, health providers. IPOST helps health providers guide and support that allows a person to communicate his or her preferences for key patients and their families during this sensitive time. A completed life-sustaining treatments including: resuscitation, general scope IPOST creates a clear declaration of the patient’s healthcare of treatment, artificial nutrition and more. IPOST is appropriate treatment choices and ensures that the patient’s wishes are for an individual who is frail, elderly or who has a chronic, critical fulfilled at the prescribed time. Contact your cnursease ma ornager or medical condition or terminal illness. social worker to learn more or to fill out the form.

If you need information on Advance Directives, or if you have questions about preparing your own Advance Directive, tell your nurse, or contact the nursing station on your unit.

You are a full partner in your hospital care. NOTICE OF PRIVACY POLICIES 7

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION HEALTH CARE OPERATIONS. We may use or disclose your health ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU information for our health care operations. For example, medical CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW staff members or members of our workforce may review your health IT CAREFULLY. information to evaluate the treatment and services provided, and the performance of our staff in caring for you. In some cases, we will furnish We are required by law to maintain the privacy of your health other qualified parties with your health information for their health information and to give you our Notice of Privacy Practices (this care operations. The ambulance company, for example, may also want “Notice”) that describes our privacy practices, legal duties and your information on your condition to help them know whether they have rights concerning your health information. done an effective job of providing care. If state law requires, we will obtain your permission prior to disclosing your health information to We follow the confidentiality protections of 42 C.F.R. Part 2 for substance other providers or health insurance companies for their health care use disorder-related records and the Affiliates who operate Part 2 operations. programs also follow the privacy practices described in Appendix A. CONTACTING YOU. We may contact you for a variety of reasons, WHO WILL FOLLOW THIS NOTICE such as to remind you of an appointment for treatment or to provide you with information about treatment alternatives or other health- THE UNITYPOINT HEALTH ACE. This Notice describes the related benefits and services that may be of interest to you. If you privacy practices of the UnityPoint Health Affiliated Covered Entity provide us with your mobile telephone number, we may contact you (the “UnityPoint Health ACE”), the participants of which are listed in by call or text message at that number for treatment-related purposes Appendix B (the “Affiliates”). such as appointment reminders, wellness checks, registration instructions, etc. We will identify UnityPoint Health as the sender of THE UNITYPOINT HEALTH OHCAS. This Notice may be the communication and provide you with a way to “opt out” and not followed by participants of one or more of the Organized Health receive further communication in this manner. With your consent, we Care Arrangements (“OHCAs”) listed in Appendix C, if designated may contact you on your mobile phone for certain other purposes. as following a joint notice. The participants of the OHCAs must be able to share your health information freely for treatment, payment FUNDRAISING. We may use and disclose your health information and health care operations relating to the purposes of the OHCAs as for the purpose of raising money for one or more of our organizations described in this Notice. listed in Appendix B. For example, we may disclose certain information about you to a foundation supporting an Affiliate so that the HOW WE MAY USE AND DISCLOSE YOUR HEALTH foundation may contact you to raise money on behalf of the Affiliate. INFORMATION You will have the right to opt out of receiving such communications with each solicitation. Please note that we will promptly process your The following are general descriptions of the types of uses and request to be removed from our fundraising list, and we will honor disclosures we may make of your health information without your your request unless we have already sent a communication prior to permission. Where state or federal law restricts one of the described receiving notice of your election to opt out. uses or disclosures, we follow the requirements of such law. FACILITY DIRECTORY. We may disclose certain information about TREATMENT. We will use and disclose your health information for you while you are an inpatient at any UnityPoint Health hospital unless treatment. For example, nurses, physicians, students and others who prohibited by state or federal law. You have the right to request that are involved in your care at a UnityPoint Health Affiliate can view your name not be included in the directory. your health information in our electronic medical record system. We will also disclose your health information to your physician and other FAMILY, FRIENDS OR OTHERS. We may disclose certain information practitioners, providers and health care facilities that provide care for about you to a family member, your personal representative or another you at their sites, for their use in treating you. For example, if you are person identified by you if you do not object or we think it’s in your best transferred from one of our hospitals to a nursing facility, we will send interest to do so. If any of these individuals are involved in your care health information about you to the nursing facility. or payment for care, we may also disclose such health information as is directly relevant to their involvement. We may also disclose your PAYMENT. We will use and disclose your health information for information to an entity assisting in disaster relief efforts so that your payment purposes. For example, we will use your health information to family or individual responsible for your care may be notified of your prepare your bill and we will send health information to your insurance location and condition. company with your bill. We may also disclose health information about you to other health care providers, health plans and health care REQUIRED BY LAW. We will use and disclose your information clearinghouses for their payment purposes. For example, if you are as required by federal, state or local law, including disclosures to brought in by ambulance, the information collected will be given to the Secretary of the Department of Health and Human Services to the ambulance provider for its billing purposes. If state law requires, evaluate our compliance with privacy laws. we will obtain your permission prior to disclosing to other providers or health insurance companies for payment purposes. NOTICE OF PRIVACY POLICIES 8

PUBLIC HEALTH ACTIVITIES. We may disclose health information DECEASED INDIVIDUALS. Following your death, we may disclose about you for public health activities, including: health information to a coroner or to a medical examiner and to funeral directors as authorized by law. We are required to apply safeguards to • to a public health authority authorized by law to collect or protect your health information for 50 years following your death. receive such information for the purpose of preventing or controlling disease, injury or disability; ORGAN, EYE OR TISSUE DONATION. We may disclose health information to organ, eye or tissue procurement, transplantation or • to appropriate authorities authorized to receive reports of child banking organizations or entities. abuse and neglect; RESEARCH. Under certain circumstances, we may use or disclose • to FDA-regulated entities for purposes of monitoring or your health information for research, subject to certain safeguards. reporting the quality, safety or effectiveness of FDA-regulated We may disclose health information about you to people preparing to products; conduct a research project, but the information will stay on site.

• to notify a person who may have been exposed to a disease THREATS TO HEALTH OR SAFETY. Under certain circumstances, or may be at risk for contracting or spreading a disease or we may use or disclose your health information to prevent a serious condition; and and imminent threat to health and safety.

• with parent or guardian permission, to send proof of required SPECIALIZED GOVERNMENT FUNCTIONS. We may use and immunization(s) to a school. disclose your health information for national security and intelligence activities authorized by law or for protective services of the President. ABUSE, NEGLECT OR DOMESTIC VIOLENCE. To the extent If you are a military member, we may disclose to military authorities required or permitted by law, we may notify the appropriate under certain circumstances. If you are an inmate of a correctional government authority if we believe an individual has been the victim institution or under the custody of a law enforcement official, we may of abuse, neglect or domestic violence. disclose to the institution, its agents or the law enforcement official HEALTH OVERSIGHT ACTIVITIES. We may disclose health your health information. information to a health oversight agency for activities authorized by WORKERS’ COMPENSATION. We may disclose health information law. about you as authorized by law for workers’ compensation or similar LEGAL PROCEEDINGS. If you are involved in a lawsuit or a dispute, programs that provide benefits for work-related injuries or illness. we may disclose health information about you in response to a court or INCIDENTAL USES AND DISCLOSURES. There are certain administrative order or in response to a subpoena, discovery request or incidental uses or disclosures of your information that occur while we other lawful process by someone else involved in the dispute, but only are providing service to you or conducting our business. For example, if reasonable efforts have been made to notify you of the request or to after surgery the nurse or doctor may need to use your name to obtain an order from the court protecting the information requested. identify family members that may be waiting for you in a waiting area. LAW ENFORCEMENT. We may disclose certain health information Other individuals waiting in the same area may hear your name called. to law enforcement authorities for law enforcement purposes, such as: We will make reasonable efforts to limit these incidental uses and disclosures. • as required by law, including reporting certain wounds and physical injuries; HEALTH INFORMATION EXCHANGES. We participate in one or more electronic health information exchanges, which permit us to • in response to a court order, subpoena, warrant, summons or exchange health information about you with others who are permitted similar process; to access your health information. Please note that the records of all of our patients will be accessible through the HIEs with which • to identify or locate a suspect, fugitive, material witness or we participate, regardless of the state affiliation and our patients’ missing person; locations of care. If you do not want your health information shared with providers through an HIE, you may contact the Privacy Officer • about the victim of a crime if we obtain the individual’s at the contact information below to obtain information on how to opt agreement or, under certain limited circumstances, if we are out. If required by law to inform you of our participation in a specific unable to obtain the individual’s agreement; HIE, we have listed the HIE on Appendix D.

• to alert authorities of a death we believe may be the result of BUSINESS ASSOCIATES. We will disclose your health information criminal conduct; to our business associates and allow them to create, use and disclose your health information to perform their services for us. For example, • information we believe is evidence of criminal conduct we may disclose your health information to an outside billing company occurring on our premises; and who assists us in billing insurance companies. • 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. NOTICE OF PRIVACY POLICIES 9

USES AND DISCLOSURES REQUIRING YOUR AMENDMENT. You may request that we amend certain health AUTHORIZATION information that we keep in your records if you believe that it is incorrect or incomplete. We are not required to make all requested There are many uses and disclosures we will make only with your amendments. If we deny your request, we will provide you with a written authorization. These include: written explanation of the reasons and your rights.

• Uses and Disclosures Not Described Above. We will obtain ACCOUNTING. You have the right to receive a list of certain your authorization for uses and disclosures of your health disclosures of your health information made by us or on our behalf. information that are not described in the Notice above. The first list in any 12-month period will be provided to you for free; you may be charged a fee for each subsequent list you request within • Many uses or disclosures of Psychotherapy Note. the same 12-month period. psychotherapy notes require your authorization. CONFIDENTIAL COMMUNICATIONS. You have the right to • We will not use or disclose your protected health Marketing. request that we communicate with you about your health information information for certain marketing purposes without your in a different way or at a different place. We will agree to your request authorization. if it is reasonable and specifies the alternate means or location to • Sale. Unless otherwise permitted by law, we will not sell your contact you. protected health information to third parties without your NOTICE IN THE CASE OF BREACH. You have the right to receive authorization. notice of an access, acquisition, use or disclosure of your health If you provide authorization for the disclosure of your health information that is not permitted by HIPAA, if such access, acquisition, information, you may revoke it at any time by giving us notice in use or disclosure compromises the security or privacy of your PHI (we accordance with our authorization policy and the instructions in our refer to this as a breach). authorization form. Your revocation will not be effective for uses and HOW TO EXERCISE THESE RIGHTS. All requests to exercise these disclosures made in reliance on your prior authorization. rights must be in writing. We will follow written policies to handle requests, respond to you within the stated timeframes and as required YOUR RIGHTS by law, and notify you of our decision or actions and your rights. For more information or to obtain request forms, contact the Privacy ACCESS TO HEALTH INFORMATION. You have the right to request Officer using the contact information at the end of this Notice. paper or electronic access to inspect and obtain a copy of the health information we maintain about you, with some exceptions. We will COMPLAINTS. If you have concerns about any of our privacy provide the information to you in the form and format you requested, practices or believe that your privacy rights have been violated, you assuming it is readily producible. If not, we will produce it another may file a complaint with the UnityPoint Health ACE using the contact readable electronic form we agree to. We may charge a cost-based fee information at the end of this Notice. You may also submit a written for producing and sending copies or, if you request one, a summary. If complaint to the U.S. Department of Health and Human Services. You you direct us to transmit your health information to another person, will not be penalized or retaliated against for filing a complaint. we will do so, provided your signed, written direction clearly designates the recipient and location for delivery. ABOUT THIS NOTICE You have the right to request a REQUEST FOR RESTRICTIONS. We are required to follow the terms of the Notice currently in effect. restriction or limitation on the health information we use or disclose We reserve the right to change our practices and the terms of this about you for treatment, payment or health care operations or to Notice and to make the new practices and notice provisions effective persons involved in your care or payment for your care. We are not for all health information that we maintain. Before we make such always required to agree to your request, except if you request that changes effective, we will make available the revised Notice by posting we not disclose certain health information to your health plan for it in physical locations where we deliver care, where copies will also payment or health care operations purposes if (1) you pay out-of- be available. The revised Notice will also be posted on our website at pocket in full for all expenses related to that service either at the time www.unitypoint.org. You are entitled to receive this Notice in writing at of service or within timeframes specified by our written policies and any time. For a written copy, please contact the Privacy Officer using (2) the disclosure is not otherwise required by law. the contact information at the end of this Section. Certain independent providers provide services at the Affiliates. You must make a separate request to each of these covered entities from whom you will receive services that are involved in your request for any type of restriction. Contact the UnityPoint Health ACE or Affiliate Privacy Officer at the contact information listed below if you have This Notice does not form a contract with you. questions regarding which covered entity/providers will be involved in your care. EFFECTIVE DATE OF NOTICE: August 3, 2020. NOTICE OF PRIVACY POLICIES 10

Individuals Involved in Your Care. Depending on your age and APPENDIX A: mental capacity and the location of your services, we may be In addition to the privacy protections afforded to all medical records permitted to make certain disclosures of your information to under HIPAA, the confidentiality of substance use disorder records your guardian, for payment purposes, and your guardian may be are protected by another federal law referred to as Part 2. Certain permitted to consent to disclosures of your information. UnityPoint Health Affiliates operate Part 2 covered programs, and this Appendix is intended to provide patients of those programs Deceased Patients. We may disclose your information relating to with a summary of the laws and regulations governing substance cause of death under laws requiring the collection of death or other use disorder treatment records, which can be found at 42 U.S.C. vital statistics or permitting inquiry into the cause of death. §290dd-2 and 42 C.F.R. Part 2 (“Part 2”). Judicial Proceedings. We may disclose information about you DISCLOSURES OF INFORMATION SUBJECT TO FEDERAL in response to a court order and subpoena that comply with the SUBSTANCE USE DISORDER RULES requirements of the regulations. The following is a summary of the limited circumstances under Qualified Service Organizations. We will disclose your information which we may acknowledge your presence or disclose information to our qualified service organizations to the extent necessary for about you to individuals outside UnityPoint Health without your these entities to provide services to UnityPoint Health. permission. VIOLATIONS OF LAWS AND REGULATIONS. A violation of Medical Emergencies. We may disclose your information to the federal law and regulations governing the confidentiality of medical personnel to the extent necessary to meet a bona fide substance use disorder records is a crime. Suspected violations medical emergency during which you are unable to provide prior may be reported to the Substance Abuse and Mental Health informed consent of the disclosure. We may also disclose your Services Administration Center for Substance Abuse Treatment at identifying information to medical personnel of the Food and 5600 Fishers Lane Rockville, MD 20857 or (240) 276-1660 or to Drug Administration (“FDA”) who assert a reason to believe that the US Attorney for the district in which the violation occurred. your health may be threatened by an error in the manufacture, labeling, or sale of a product under FDA jurisdiction, and that the Central District of Illinois information will be used for the exclusive purpose of notifying One Technology Plaza patients or their physicians of potential dangers. 211 Fulton Street, Suite 400 Peoria, IL 61602 Research: Under certain circumstances, we may disclose your (309) 671-7050 information for scientific research, subject to certain safeguards. Southern District of Iowa Audit and Evaluations. We may disclose information to others for U.S. Courthouse Annex specific audits or evaluations, including those who provide financial 110 East Court Avenue # 286 assistance to UnityPoint Health or those who conduct audits Des Moines, Iowa 50309-2053 and evaluations necessary under federally-funded health care (515) 473-9300 programs and federal agencies with oversight of those programs. Northern District of Iowa Reporting Certain Criminal Conduct. The following information 111 7th Ave, SE is not protected by Part 2: Box #1 Cedar Rapids, IA 52401 • Information related to your commission of a crime on the (319) 363-6333 premises of a UnityPoint Health facility; Western District of Wisconsin • Information related to your commission of a crime against 222 West Washington Ave, UnityPoint Health personnel; and Suite 700 Madison, WI 53703 • Reports of suspected child abuse and neglect made under (608) 264-5158 state law to the appropriate state or local authorities. NOTICE OF PRIVACY POLICIES 11

APPENDIX B: Stewart Memorial Community Hospital Story County Medical Center Sumner Community Club dba LIST OF PROVIDERS COVERED UNDER THIS NOTICE OF - Community Memorial Hospital PRIVACY PRACTICES The Dubuque Visiting Nurse Association IOWA The Finley Hospital dba - UnityPoint at Home – Dubuque Allen Health Systems, Inc. dba The Robert Young Center for Community Mental Health dba - UnityPoint Health - Waterloo - Robert Young Center Allen Memorial Hospital Corporation dba - The Robert Young Mental Health Center - Allen Hospital Trinity Health Enterprises, Inc. Anamosa Area Ambulance Service Trinity Medical Center Black Hawk-Grundy Mental Health Center, Inc. Trinity Regional Medical Center Buena Vista Regional Medical Center Unity HealthCare dba Center for Alcohol and Drug Services, Inc. - Trinity Muscatine Central Iowa Health System UnityPoint At Home dba Central Iowa Hospital Corporation dba - Paula J. Baber Hospice Home (IPU) - Ankeny Medical Park - Taylor House (IPU) - Blank Children’s Hospital - UnityPoint Hospice - Iowa Lutheran Hospital UnityPoint Health – Marshalltown - Iowa Methodist Medical Center Younker Rehabilitation Therapy Services, LLC - John Stoddard Cancer Center - Methodist West Hospital - UnityPoint Health – Des Moines ILLINOIS: Clarke County Hospital Center for Alcohol and Drug Services, Inc. Finley Tri-States Health Group, Inc. Iowa Physicians Clinic Medical Foundation dba Greater Regional Medical Center dba - UnityPoint Clinic -Greater Regional Health Methodist Health Services Corporation Greene County Medical Center Pekin Memorial Hospital dba Grinnell Regional Medical Center -UnityPoint Health Pekin Grundy County Memorial Hospital Proctor Hospital Humboldt County Memorial Hospital The Methodist Medical Center of Illinois Iowa Physicians Clinic Medical Foundation dba The Robert Young Center for Community Mental Health dba - UnityPoint Clinic - Robert Young Center Loring Hospital - The Robert Young Mental Health Center Lucas County Health Center Trinity Health Enterprises, Inc. Marengo Memorial Hospital dba Trinity Medical Center - Compass Memorial Healthcare UnityPoint Health – Central Illinois North Central Iowa Mental Health Center, Inc. dba - Berryhill Center WISCONSIN: Northwest Iowa Hospital Corporation dba Meriter Enterprises, Inc. - St. Luke’s Regional Medical Center of Sioux City - Meriter Laboratory Pocahontas Community Hospital Meriter Health Services, Inc. Siouxland Pace, Inc. Meriter Hospital, Inc. Sioux Valley Memorial Hospital Association dba - Cherokee Regional Medical Center St. Luke’s Healthcare St. Luke’s Health Resources dba - Occupational Medicine

St. Luke’s Methodist Hospital

St. Luke’s/Jones Regional Medical Center dba - Jones Regional Medical Center NOTICE OF PRIVACY POLICIES 12

All independent practitioners are solely responsible for their APPENDIX C: judgment and conduct in treating or providing professional UnityPoint Health participates in one or more Organized Health services to patients and for their compliance with state and Care Arrangements (“OHCAs”). OHCAs can take one of two federal laws. Nothing in this Notice is meant to imply or create an forms. First, an OHCA can be a clinically integrated care setting employment relationship between any independent physician or in which patients receive health care services from more than other practitioner and us. This Notice does not change or limit any one independent health care provider. Next, an OHCA can be an consents for treatment or procedures the patient may sign during organized system of health care in which multiple independent the time the patient receives care from any of us. covered entities participate in joint health care-related activities including utilization review, quality assessment and improvement When applicable, we use a joint Notice of Privacy Practices and activities, or certain payment activities. a joint Acknowledgement Form with independent physicians and other practitioners to reduce paperwork and make it easier to share This Appendix lists the OHCAs in which UnityPoint Health information to improve your care. The OHCA does not cover the participates and describes whether and to what extent the OHCA information practices of practitioners in their private offices or at participants follow this Notice. other practice locations.

MEDICAL STAFF The UnityPoint Health ACE Affiliate Hospitals and the members APPENDIX D: of their respective medical staffs participate in an OHCA. Our LIST OF HEALTH INFORMATION EXCHANGES REQUIRED medical staff is made up of physicians, nurse practitioners and TO BE DISCLOSED other eligible health care professionals who provide health care Iowa Health Information Network (IHIN) services in our hospitals, clinics and other sites. The medical staff To opt out or for more information visit ihin.org. will follow this Notice when using or disclosing health information related to inpatient or outpatient hospital services rendered through our facilities.

UNITYPOINT HEALTH’S ACOS The UnityPoint Health ACE and providers of UnityPoint Health’s Accountable Care Organization (“ACO”) also participate in an OHCA. We share information with providers in the ACO to carry out the health care operations of the ACO, which may include, for example, information regarding a physician’s compliance with ACO protocols in the physician’s treatment of you.

UnityPoint Health-Meriter, Iowa Physicians Clinic Medical Foundation (UPC), UnityPoint at Home participate in an OHCA with University of Wisconsin Hospitals and Clinics Authority (UWHC) and University of Wisconsin Medical Foundation (UWMF). UWHC and UWMF are collectively referred to as UW Health. These members participate in a joint operating agreement to clinically align their operations within a geographic area to provide timely access and coordinated medical care within the Madison region and surrounding communities. The members share information to carry out their joint health care operations under the joint operating agreement, including, for example, business planning activities and coordinating managed care contracting. NOTICE OF PRIVACY POLICIES 13

APPENDIX E: (319) 235-3913 NONDISCRIMINATION/ACCESSIBILITY NOTICE UnityPoint Health does not discriminate, exclude, or treat people (319) 235-3913 differently on the basis of race, color, national origin, age, disability, or sex. We provide the following for free: (319) 235-3913 • Communication aids and services to people with disabilities, such as: (319) 235-3913. - Sign language interpreters - Written information in other formats (319) 235-3913 • Language services to people whose primary language is not English, such as: - Interpreters (319) 235-3913 - Information written in other languages A Patient Representative is available if you need these services. A (319) 235-3913 Patient Representative is also available to help you file a grievance if you believe that we have failed to provide these services or (319) 235-3913. discriminated on the basis of race, color, national origin, age, disability, or sex. To connect with a Patient Representative, contact (319) 235-3913 the Privacy Officer (see “Contact Information”). You can also file a complaint with the U.S. Department of Health (319) 235-3913. and Human Services, Office for Civil Rights, electronically at https:// ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: (319) 235-3913. U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, (319) 235-3913. HHH Building Washington, D.C. 20201 (319) 235-3913. 1-800-368-1019, 1-800-537-7697 (TDD) (319) 235-3913. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html (319) 235-3913. FINANCIAL ASSISTANCE PROGRAM 14

PLAIN LANGUAGE SUMMARY OF UNITYPOINT HEALTH – facilities through a patient’s participation in the UnityPoint Health – MARSHALLTOWN FINANCIAL ASSISTANCE POLICY Marshalltown Financial Assistance Program. All patients requesting UnityPoint Health –Marshalltown offers financial assistance to many financial assistance through the UnityPoint Health – Marshalltown people who have health care needs and are not able to pay for care. Financial Assistance Program are required to participate in the UnityPoint Health does not want a person’s ability to pay their bill Eligibility Determination Process below. All patient requesting financial to stop them from getting care. This is a summary of the UnityPoint assistance will be treated fairly, with dignity, compassion and respect. Health –Marshalltown Financial Assistance Policy (FAP). Patients start the Financial Assistance process by completing an application and returning the application and supporting AVAILABILITY OF FINANCIAL ASSISTANCE documents to: You may be able to get financial assistance if you are not able to pay Patient Financial Advocates your health care bill. UnityPoint Health – Marshalltown gives financial UnityPoint Health –Marshalltown assistance for required medical services. Optional services, such as 3 South 4th Avenue cosmetics, will not receive financial assistance. Marshalltown, IA 50158

FINANCIAL ASSISTANCE Or for help with financial assistance, patients may contact (641) 854- 7990 or visit in person at: Patient Financial Coordinator Office (in Financial assistance, in the form of a discount (meaning a deduction Emergency Room registration area). made from the provider’s standard charge), is available for medically necessary healthcare services at UnityPoint Health – Marshalltown 002842a.mt.1 8-2020