Baptist Health Notice of Privacy Practices



This Notice describes the privacy practices of Baptist Healthcare System, Inc., and Our affiliated covered entities (collectively referred to as “Baptist,” “We,” ”Our” or “Us”) when you are treated as a patient at one of these facilities. An Affiliated Covered Entity (“ACE”) is a group of Covered Entities, Health Care Providers and Health Plan under common ownership or control that designates itself as a single entity for purposes of compliance with the Health Insurance Portability and Accountability Act (“HIPAA”). The members of the Baptist ACE will share Protected Health Information (“PHI”) with each other for the treatment, payment and health care operations of the Baptist ACE and as permitted by HIPAA and this Notice. Baptist may add or remove Covered Entities from the Baptist ACE. For a complete current list of the members of the Baptist ACE, please visit our website at Notice also applies to services provided at other locations by Baptist employees, contractors, volunteers, students or representatives, including but not limited to services in your home, diagnostic centers, urgent care centers, occupational medicine clinics, physician offices, fitness centers, mobile health services, and critical care transport services. 


We have an organized health care arrangement (“OHCA”) with the independent health care providers on our medical staffs, which include but are not limited to physicians, psychologists, certified nurse anesthetists, nurse practitioners, and physician assistants.  Most of these providers are not employed by Baptist and are not agents for Baptist.  However, it is necessary for them to share information to manage your care and to improve Our services.  Those providers who participate in Our OHCA agree to follow the terms of this Notice and are included in references to Baptist, We, Our or Us in this Notice.  This Notice serves as a joint notice of privacy practices for these providers and Baptist.  If these independent providers treat you at another facility not operated by Baptist, you will receive separate notices from them. 


Protecting Your Information


We understand that certain information about you and your health is personal.  We are committed to protecting medical, billing and other information about you.  If you have a personal representative as defined by applicable law, such as a legal guardian, we will treat that person the same as you with respect to uses and disclosures of your protected health information as well as your individual rights.


We create a record of the care and services you receive at or by Baptist.  We need this record to provide you with quality care and to comply with certain legal requirements.  This Notice will tell you about the ways in which We use and disclose information about you.  It also describes your rights and Our duties regarding the use and disclosure of your information. We reserve the right to change this Notice and 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 on Our Web site ( and it will also be available at the Registration or Admitting Department at all facilities covered by the Notice.  The effective date of the Notice is located at the bottom of each page.  We are required by law to (1) maintain the privacy of medical information that identifies you, (2) give you this Notice of Our legal duties and privacy practices, and (3) follow the terms of Our most current Privacy Notice.


Use and Disclosure of Information about You 


The following categories describe different ways that We are permitted to use and disclose medical information.  These examples are not exhaustive. 


  • For Treatment. We may use your medical information to provide, coordinate, or manage your health care and any related services. We may disclose your medical information to employees, students, volunteers, physicians, other health care providers, and other individuals who are involved in providing treatment to you. For example, We may provide a physician who is treating you for a broken leg with information about another medical condition you may have, such as diabetes, because diabetes may slow the healing process. In addition, the physician may need to tell the dietitian if you have diabetes so that We can arrange for appropriate meals. This type of information sharing may occur through the use of an Electronic Health Record or through our participation in an electronic health exchange designed to facilitate sharing patient information for treatment purposes. Different departments also may share medical information about you in order to coordinate the different services and products you need, such as prescriptions, lab work and x-rays. We also may disclose medical information about you to people outside of Baptist or Our OHCA who are involved in your medical care, such as home health agencies, nursing homes, physicians, medical device or equipment companies, pharmacists, ambulance service providers, or others who provide services that are part of your care.
  • For Payment. We may use and disclose information about you so that the treatment and services you receive may be billed and payment may be collected from you, an insurance company or a third party. For example, We may need to give your health plan information about surgery you received at Baptist so your health plan will pay Us or reimburse you for the surgery. We may also tell your health plan about a treatment you are going to receive in order to obtain prior approval or to determine whether your plan will cover the treatment. We may also share your information with companies that provide billing or collection services for Us. We may allow companies to review information about you to evaluate your eligibility for receiving medical assistance, qualify you for such assistance, and arrange for payment. Also, We may disclose your information to another health care provider who provides treatment or services to you, such as an ambulance service, in order for that provider or service to receive payment.
  • For Health Care Operations. We may use and disclose information about you for health care operations. These uses and disclosures are necessary to provide quality health care and to support the daily activities related to health care. These uses and disclosures may occur through the use of an Electronic Health Record or through our participation in an electronic health exchange with other health care providers. These activities include but are not limited to quality assessment and improvement activities, utilization reviews, investigations, oversight or staff performance reviews, training programs, review and auditing, including compliance reviews and medical reviews, conducting or arranging for other health related activities, underwriting and other insurance-related activities, business planning or development, and internal grievance resolution. For example, We may use medical information to review treatment and to evaluate the performance of Our staff and independent health care providers who care for you. We may also combine medical information about many patients to decide what additional services We should offer, what services are not needed, and whether certain new treatments are effective. We may disclose patient information to agencies or companies for accreditation, certification, licensing, or credentialing activities. We may also combine the information We have with information from other facilities to compare how We are doing and to see where We can make improvements in the care and services We offer. We also may use or disclose patient information in conducting or arranging for legal, financial, auditing, risk management, consulting, management, and administrative services. We may use or disclose your information in Our fraud and abuse detection and compliance programs. In certain situations, We also may disclose your information to third parties for their own health care operations activities.
  • Activities of Our Organized Health Care Arrangement (OHCA).Members of Our OHCA share information about you in order to provide quality treatment, to obtain payment for the services, and to carry out health care operations related to the arrangement. Most providers who participate in Our OHCA are not agents for Baptist or each other. Baptist and participating providers are not responsible for each other’s actions.
  • Appointment Reminders. We may use and disclose your information to remind you of an appointment with Us.
  • Treatment Alternatives, Health-Related Benefits and Services. We may use and disclose your information to discuss treatment alternatives and health-related benefits or services that may be of interest to you, so long as We don’t receive any payment in exchange for such communication.
  • Fundraising Activities. We may use information about you to contact you in an effort to raise money to support Baptist and its operations. We may disclose information to a foundation related to Baptist or a Business Associate so that they may contact you with these giving opportunities. We are permitted to use and disclose limited information about you called demographic information, along with the dates you received services, your health insurance status, the department and/or practitioner who provided your services, and outcome information. You have a right to opt out of receiving fundraising communications, and We will tell you how to stop receiving them in any fundraising communications We send.
  • Directory. Our hospitals include limited information about you in the patient information directory, such as your name, location in the facility, and general condition. We usually give this information to people who ask for you by name so that they can visit you in the hospital and generally know how you are doing. We also may include your religious affiliation in the directory and we share this limited information with clergy from the community. You are free not to share your religious affiliation with Us if you do not want that information shared with clergy. We do not release this information if you are being treated on a behavioral health or substance abuse care unit. If you do not want your information included in Our directory, please let Us know.
  • Individuals Involved in Your Care or Payment for Your Care. As long as you do not object, We may share or discuss your medical information with family, friends, or others involved in your care or payment for your care if your provider believes, in his or her professional judgment, that it is in your best interest. Your provider may ask your permission, may tell you he or she plans to discuss the information and give you an opportunity to object, or may decide, using his or her professional judgement, that you do not object. In such cases, your provider will discuss only the information that the person involved needs to know about your care or payment for your care. This does not apply to patients receiving treatment for certain conditions, such as substance/alcohol abuse. In addition, We also may disclose information about you to an organization or agency assisting in disaster relief efforts so that your family can be notified about your condition and location.
  • Research. Medical research is vital to the advancement of medical science. We generally ask for your written authorization before using your health information or sharing it with others to conduct research. Under limited circumstances, we may use and disclose your health information without your authorization for health research. In the latter situations, we must comply with special processes required by law that reviews protections for patients involved in research, including privacy. Researchers may also contact you to see if you are interested in or eligible to participate in a study.
  • As Required By Law. We will disclose information about you when required or authorized by state or federal law. For example, the Secretary of the Department of Health and Human Services may require that We disclose information to confirm our compliance with HIPAA and We have a legal obligation to comply with such requests under federal law.
  • To Avert a Serious Threat to Health or Safety. We may use and disclose information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
  • Military and Veterans. If you are a member of the armed forces, We may release medical information about you if required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
  • Workers' Compensation. We may release information about you for workers' compensation or similar programs, as permitted or required by law. These programs provide benefits for work-related injuries or illness.
  • Public Health Risks. We may disclose information about you for public health activities. These activities generally include but are not limited to the following, as permitted or required by law: (1) preventing or controlling disease, injury or disability; (2) reporting births and deaths; (3) collecting or reporting adverse events and product defects, tracking FDA regulated products, and enabling product recalls, repairs or replacements; (4) notifying the appropriate government authority if We believe a patient has been the victim of abuse, neglect or domestic violence; and (5) notifying 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 but are not limited to audits, investigations, inspections, licensure and certification. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
  • Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, We may disclose information about you in response to a court or administrative order. We may also disclose information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute if We receive satisfactory assurances that attempts have been made to notify you or your attorney about the request or to secure a protective order. If you are involved in a lawsuit or dispute against Baptist, We may share your information as necessary to support Baptist’s position and to obtain legal services.
  • Law Enforcement. We may release information if asked by a law enforcement official such as (1) in response to a court order, subpoena, or warrant; (2) to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime; (4) about a death or health condition that We believe may be the result of criminal conduct; and (5) to report a crime committed on Baptist premises.
  • Coroners, Funeral Directors and Organ Donation. We may disclose information to coroners or medical examiners for identification purposes, to determine the cause of death, or for them to perform other duties authorized by law. We may also release information to funeral directors as necessary for them to carry out their duties. We may use or disclose information for cadaveric organ, eye or tissue donation purposes.
  • Specific Government Functions. In certain situations, federal laws authorize Us to use or disclose your medical information to facilitate specified government functions relating to military and veteran activities, national security and intelligence activities, protective services for the President and others, medical suitability determinations, correctional institutions, and law enforcement custodial situations.
  • Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, We may release information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.


    Your Rights Regarding Information about You


  • Right of Access. You have the right to inspect and obtain a copy of information that We maintain about you. Usually, this includes medical and billing records, but does not include certain other types of records. You have the right to request a copy of the information in an electronic format. If possible, We will provide the information in the electronic format you request. If We are unable to produce the information in the electronic format you request, We will offer you the information in another electronic format. To inspect or request a copy of the available records, you must submit your request in writing to the Health Information Management (“HIM”) or Medical Records Department of the facility that treated you. Under certain circumstances, We may charge you a fee for copying and mailing your records, and for supplies used to create the copy which may include the cost of portable media if you have requested the information in electronic format. We may deny your request to inspect or obtain a copy in certain limited circumstances. If you are denied access to information, you may request that the denial be reviewed in certain circumstances. 
  • Right to Amend. If you feel that 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 Us. To request an amendment, you must submit a written request, along with a reason that supports your request, to the HIM or Medical Records Department of the facility that treated you. If we accept your request, we will tell you and will amend your records. We may not be able to take out what is in the record, but we will supplement the information. We may deny your request 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 (1) was not created by Us, unless the person or entity that created the information is no longer available to make the amendment; (2) is not part of the medical information kept by or for Us; (3) is not part of the information that you would be permitted to inspect and copy; or (4) is already accurate and complete as originally stated. 
  • Right to Receive an Accounting. You have the right to receive an accounting or list of certain disclosures made by Us, upon your request. This right does not apply to disclosures (1) made to you or in response to an authorization form signed by you; (2) for national security or intelligence purposes; (3) for a facility directory; (4) made to your friends or family members involved in your care; (5) that are incident to a permitted use or disclosure; (6) made to correctional institutions or in law enforcement custodial situations; (7) made as part of limited data set as permitted by HIPAA; and (8) to carry out treatment, payment, and health care operations. To request an accounting, you must submit your request in writing to the HIM or Medical Records Department of the facility that treated you. The request may not cover a time period longer than six years prior to the date of the request. The first list you request within a 12-month period will be free. For additional lists, We may charge you a reasonable fee. 
  • Right to Request Restrictions. You have the right to request a restriction or limitation on the 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 information that We disclose to someone who is involved in your care or the payment for your care, like a family member or friend.  Your request must be submitted in writing to the HIM or Medical Records Department of the facility that treated you.  Your request must state the specific restriction requested and to whom you want the restriction to apply.  In most cases, We are not required to agree to a requested restriction.  However, We are required to agree when you ask Us to refrain from disclosing your information to a health plan if the disclosure would be for the purpose of payment or health care operations, and if the information pertains solely to a health care item or service that you have paid for in full and out of pocket.  If We agree to a restriction or limitation, We will comply with your request unless the information is needed to provide emergency treatment. 
  • 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 may ask that We contact you only at work or by mail. To request confidential communications, you must make your request in writing to the Registration, Admitting, HIM or Medical Records Department at the facility that treated you. 
  • Right to Receive Breach Notifications. You have a right to receive notifications from Us if the privacy or security of your protected health information is breached. 
  • Right to a Paper Copy of This Notice. You have the right to obtain a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may obtain a paper copy of Our current Notice by contacting the Registration or Admitting Department at all facilities. You may also visit Our Web site (


Other Uses of Medical Information Requiring Your Written Authorization


Certain uses and disclosures of your protected health information are only permitted with your written permission by signing an authorization form.  These include most uses and disclosures of psychotherapy notes, certain uses and disclosures of your protected health information for marketing communications, and disclosures that constitute the sale of your protected health information. 


Other uses and disclosures of information not covered by this Notice or the laws that apply to Us will be made only with your written permission by signing an authorization form.  If you give Us authorization to use or disclose information, you may revoke that authorization, in writing, at any time.  If you revoke your authorization, We will no longer use or disclose information about you for the reasons covered by your written authorization.   We are unable to take back any disclosures We have already made with your permission.  We are required to retain Our records of the care that We provided to you.


Other State and Federal Laws


Special restrictions may apply under state or federal law for uses and disclosures concerning certain sensitive information, such as information pertaining to mental health, substance abuse diagnosis or treatment, HIV/AIDS related testing and treatment, or sexually transmitted diseases.  When special restrictions apply to your health information, We will use and disclose the information in compliance with the applicable law. 


Questions and Complaints


If you have any questions about this Notice, please contact the appropriate Privacy Officer at the facility that treated you.   If you believe your privacy rights have been violated, you may file a complaint with Us or with the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint.  To file a complaint, you may call 1.833.204.8787 or contact the Privacy Officer at the facility that treated you.  A list of Privacy Officers is available at