Treatment you need. Support you deserve.
Plain Language Summary
In compliance with section 501(r)(6) of the Internal Revenue Code, the hospital will inform patients of its financial assistance policy and will make reasonable efforts to determine a patient’s eligibility for financial assistance. The patient will be notified in writing of the determination. If the determination is made that the individual is eligible for assistance, the hospital will reverse, when possible, the result of any collection efforts and refund any overpaid amounts to the individual. The hospital will also issue a new billing statement to the patient which represents the amount generally billed to individuals with insurance.
To request an application for financial assistance:
Call the Holton Community Hospital at (785) 364-2116
Walk into Holton Community Hospital location
Walk into any of the Family Medicine locations
Download the form electronically
Send the completed application, along with the supporting documents listed on the application to:
Holton Community Hospital, 1110 Columbine Drive, Holton, KS 66436 or
Holton Family Medicine, 1100 Columbine Drive, Suite 100, Holton, KS 66436 or
Hoyt Family Medicine, 117 West 3rd, Hoyt, KS 66440 or
Wetmore Family Medicine, 323 2nd Street, Wetmore KS 66550
In the event of non-payment of any amount determined to be the responsibility of the patient/guarantor and the absence of an application for assistance, the hospital may refer the account(s) to an outside collection agency. Such action may result in an adverse entry on the patient’s/guarantor credit rating.
Financial Assistance Eligibility Criteria
- Applicants must be screened for eligibility for any third party payor sources, such as Medicaid, and, subsequently, payment from all other payor sources must be exhausted before the applicant will be eligible for hospital financial assistance.
- Applicants must complete and submit the required application and present proof of income and spouse’s income before consideration for assistance.
- The level of assistance will be determined by comparing the applicant’s income to the Federal Poverty Guidelines (FPG):
100% discount if income is 0% to 100% of FPG;
75% discount if income is 101% to 125% of FPG
50% discount if income is 126% to 150% of FPG
25% discount if income is 151% to 175% of FPG
10% discount if income is 176% to 200% of FPG
No discount if income is over 200% FPG
Call (785) 364-2116 or visit Holton Community Hospital, 1110 Columbine Drive, Holton, KS
Rural Health Resources of Jackson County, Inc. (RHR) is a not-for-profit corporation established under laws of the State of Kansas to provide for the healthcare needs of persons who reside in Holton, Kansas and surrounding communities that include the counties of Atchison, Brown, Jackson, Jefferson, Nemaha, Pottawatomie and Shawnee. RHR qualifies as a tax-exempt organization under section 501(c)(3)of the Internal Revenue Code. In order to carry out its mission, RHR must receive adequate and timely reimbursement for goods and services provided.
The purpose of this policy is to ensure that RHR is fairly and adequately compensated for services provided; to ensure the efficient and effective utilization of the fiscal and capital resources of RHR; to ensure that fiscal operations are in accordance with generally accepted accounting principles and business practices; consistent with the regulations which govern the operation of healthcare facilities; and consistent with operating budget approved by the RHR Board of Directors.
As a participant in the Medicaid and Medicare programs Rural Health Resources of Jackson County, Inc. (RHR) shall not deny healthcare services to anyone because of an inability to pay for services. As a charitable organization the RHR Board has a written policy that provides a charitable healthcare discount for services provided to indigent patients.
In order to carry out its mission and to provide cost effective healthcare services; reduce costly billing and accounting overhead costs; it shall be the policy of RHR to require payment for services at the time of service in accordance with the following financial standards:
- For the convenience of our patients RHR shall accept cash, checks, and credit cards for payment.
- For the convenience of our patients RHR shall accept direct assignment of insurance benefits, including discounts for services, which may be negotiated between RHR and third party payers as a condition of insurance assignment. RHR business office staff shall assist a patient in evaluating third party coverage for services provided by RHR. This acceptance does not relieve the patient of the ultimate responsibility to pay for services received; to pay deductibles and copayments at or before the time of service; or to pay for services not covered by third party benefit plans.
- For the convenience of our patients RHR shall participate as a provider in the Kansas Medicaid Program, subject to the CMS conditions of participation and the State of Kansas Medicaid Rules and Regulations and shall accept direct assignment of benefits. RHR accepts assignment of Medicaid benefits as a convenience to our patients; this acceptance does not relieve the patient of the ultimate responsibility to pay for services received; to pay deductibles and copayments at or before the time of service; or to pay for services not covered by third party benefit plans.
- For the convenience of our patients RHR shall participate as a provider in the Medicare Program, subject to the CMS conditions of participation and shall accept direct assignment of benefits. RHR accepts assignment of Medicare benefits as a convenience to our patients; this acceptance does not relieve the patient of the ultimate responsibility to pay for services received; to pay deductibles and copayments at or before the time of service; or to pay for services not covered by third party benefit plans.
- Patients who have no insurance and are responsible for full payment on their account, will meet with the Patient Financial Services Manager to make a deposit that is agreeable to both parties before any procedure will be scheduled.
- The RHR Patient Payment Policy is divided into the following categories and is based on the balance due from the patient following applicable discounts as may be provided by this policy:
- $5.00 to $100.99: The account balance is due and payable within thirty (30) days from the date of billing.
- $101.00 to $200.99: The account balance is due and payable over a three (3) month period, with three (3) equal monthly payments. All payment plans shall be defined in writing and signed by the Patient Financial Services Manager and the responsible party.
- $201.00 to $500.99: The account balance is due and payable over a six (6) month period, with six (6) equal monthly payments. All payment plans shall be defined in writing and signed by the Patient Financial Services Manager and the responsible party.
- $501.00 to $1,000.99: The account balance is due and payable over a twelve (12) month period, with twelve (12) equal monthly payments. All payment plans shall be defined in writing and signed by the Patient Financial Services Manager and the responsible party.
- $1,001.00 to $3,000.99: The account balance is due and payable over an eighteen (18) month period, with eighteen (18) equal monthly payments. All payment plans shall be defined in writing and signed by the Patient Financial Services Manager and the responsible party.
- $3,001.00 to $5,000.99: The account balance is due and payable over a twenty-four (24) month period, with twenty-four (24) equal monthly payments. All payment plans shall be defined in writing and signed by the Patient Financial Services Manager and the responsible party.
- A “Prompt Pay” discount may also be considered upon the request of the Patient/Guarantor. All “Prompt Pay” discounts shall be approved and authorized by the Chief Executive Officer and/or the Patient Financial Services Manager.
- Consistent with acceptable community business standards of practice, RHR provides a monthly guarantor statement for services provided by RHR. These guarantor statements provide a summary of charges but not an itemized detail of charges. RHR patients upon request to the RHR business office or Patient Financial Services Manager shall be entitled to an itemized statement of charges; there shall be no charge to the patient and/or guarantor for this initial statement.
- An account shall be considered past due if RHR has not received any payments on the account; or a patient has made a payment to RHR less than the amount agreed to in a written payment plan. Accounts more than 120 days past due shall be subject to immediate collection proceedings in accordance with the following standards:
- a) The Patient Financial Services Manager shall ensure that at least three (3) attempts are made to contact the responsible party (guarantor) in an effort to bring the account current, prior to referring the account to a collection agency. This information shall be documented in RHR business records. A current account shall be defined as all accounts payable due to RHR by the responsible party, have been paid in full as defined and described in this policy.
- b) In the event the responsible party is unable or unwilling to bring the account current, the Patient Financial Services Manager shall take such legal action as permitted by law to recover the funds due to RHR.
- The Chief Executive Officer (or designee) shall be authorized to write-off or reduce all or part of any balance due for the cause of failure of performance by RHR. The cause for action and the balance written off shall be documented in writing in the patient’s business record. Account balances may not be written-off or reduced due to inability to pay in addition to that authorized by the RHR Charity Care Policy approved by the RHR Board.
The RHR Patient Financial Services Manager shall be responsible for ensuring that both written and verbal notification is provided to RHR patients of this financial policy. When at all possible this information shall be provided to the patient prior to providing goods or services. Compliance of this requirement shall be documented in writing in the patient medical record.
RHR staff found to be in violation of this policy shall be subject to disciplinary action including dismissal from employment.
The Patient Financial Services Manager shall be responsible for developing forms to inform RHR patients concerning this financial policy. The patient and/or responsible party and the RHR staff member informing the patient shall sign the form. The original shall be filed in the patient’s medical record and a copy shall be given to the patient.
The Patient Financial Services Manager must review and approve all payment plans, subject to the terms and conditions of this policy.
Discrimination is Against the Law
Holton Community Hospital and Holton, Hoyt and Wetmore Family Medicine complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
Holton Community Hospital and Holton, Hoyt and Wetmore Family Medicine does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Holton Community Hospital and Holton, Hoyt and Wetmore Family Medicine provides free aids and services to people with disabilities to communicate effectively, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
- Provides free language services to people whose primary language is not English, such as: qualified interpreters and information written in other languages
If you need these services, contact Holli Dieckmann, Compliance Officer.
If you believe that Holton Community Hospital and Holton, Hoyt and Wetmore Family Medicine has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Holli Dieckmann, Compliance Officer at 1110 Columbine Drive, Holton, KS 66436; phone: 785-364- 9653; fax: 785-364- 9612; or by email at: firstname.lastname@example.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Holli Dieckmann, Compliance Officer is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800- 368-1019, 800-537- 7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.
Effective as of 01/01/2016.
This Notice Describes How Medical Information About You May Be Used And Disclosed And How You Can Get Access To This Information. Please Review It Carefully.
UNDERSTANDING YOUR HEALTH INFORMATION – HOW IT IS USED AND HOW IT MAY BE SHARED WITH OTHERS: There are laws that require we maintain the privacy of your health information and tell us how we may use and disclose health information. Those laws also require that we make a copy of this Notice available to you. This Notice describes how we use and disclose your health information, and your rights pertaining to that information.
WHAT IF YOU HAVE QUESTIONS ABOUT THIS NOTICE? If you do not understand this Notice or what it says about how we may use your health information, please contact:
Holli Dieckmann, RHIT
1110 Columbine Drive
Holton, KS 66436
WHAT IS YOUR HEALTH RECORD OR HEALTH INFORMATION? When you go to a hospital, doctor, or other health care provider, a record is made that tells about your treatment. This record will have information about your illnesses, your injuries, signs of illness, exams, laboratory results, treatment given to you, and notes about what might need to be done at a later date. Your health information could contain all kinds of information about your health problems. The hospital keeps this health information and can use this information in many different ways. What we do with your health information and how we can use and share this information is what the rest of this Notice describes.
Your Rights Regarding Electronic Health Information Exchange
KANSAS – Hospital participates in electronic health information technology or HIT. This technology allows a provider or a health plan to make a single request through a health information organization or HIO to obtain electronic records for a specific patient from other HIT participants for purposes of treatment, payment, or health care operations. HIOs are required to use appropriate safeguards to prevent unauthorized uses and disclosures. You have two options with respect to HIT. First, you may permit authorized individuals to access your electronic health information through an HIO. If you choose this option, you do not have to do anything. Second, you may restrict access to all of your information through an HIO (except as required by law). If you wish to restrict access, you must submit the required information either online at http://www.KanHIT.org or by completing and mailing a form. This form is available at http://www.KanHIT.org. You cannot restrict access to certain information only; your choice is to permit or restrict access to all of your information. If you have questions regarding HIT or HIOs, please visit http://www.KanHIT.org for additional information. If you receive health care services in a state other than Kansas, different rules may apply regarding restrictions on access to your electronic health information. Please communicate directly with your out-of-state health care provider regarding those rules.
WHAT IS THE RESPONSIBILITY OF THE HOSPITAL WHEN IT COMES TO YOUR HEALTH INFORMATION? The law requires that this Hospital must do the following when it comes to handling your health information:
Keep your health information private, only giving it out when allowed by law to do so;
Explain our legal duty and our rules about keeping your health information private to you;
Follow the rules given in this Notice;
Let you know when we cannot agree with a request or demand you may make to restrict the sharing of your health information with others.
Help you when you want your health information sent in a different way than it usually is sent or to a different place than it usually is sent.
Inform you if there has been a breach of your unsecured protected health information.
We will not give out your health information without your authorization except as described in this Notice. You must sign an authorization if we use or disclose your health information for certain marketing activities, if we are paid for your health information or if we are paid for making certain communications to you based upon your health information, if we sell your health information or if the use or disclosure involves psychotherapy notes. There are laws that say when we can give out your health information to others without your permission. The Hospital will follow these laws. The Hospital can give out your health information electronically (over computer networks, for example) or by facsimile.
WHAT ARE YOUR HEALTH INFORMATION RIGHTS? Your health information is the property of the doctor or hospital that wrote it. The information contained in your health information belongs to you. You have certain rights concerning this health information. The following is a list explaining your rights:
You Have the Right to Look at Your Health Information and You Can Get a Copy of This Information Which May Be Used to Help With Your Care. This information will usually include medical and billing records. Your information will not have psychotherapy notes and information that is made to be used in a court proceeding or information covered by special laws. If you want to see your health information and get a copy of your health information, you must make a request to the Contact Person. If you are disabled or ill, you can make this request over the phone or in person. You may be charged a reasonable cost-based fee or labor fee for copies and mailing. We may refuse your request for your health information. If we refuse you, you will be told in writing. If we refuse, you can have the decision to not allow you to see your health information reviewed and a neutral person will review your request and we will do what they say.
You Have the Right to Ask That We Make Changes to Your Records. If you feel that your health information is not complete or wrong, you can ask that we change it. You can ask that we make a change to your health information for as long as we have it. If you want to make a change to your health information, you must give a good reason for the change. If you do not put your request for a change in writing and give a good reason, we may not allow the change to be made. We may also refuse your request for change for the following reasons: (1) the information was not created by this Hospital; (2) it is not a part of the health information kept by or for the Hospital; (3) it is not information you are permitted to see or copy; or (4) it is accurate and complete.
You Have a Right to a List of Individuals to Whom We Gave Your Health Information. To request a list of names to whom we gave your health information, you must write a request to the Hospital. You have to include a time period in your request. We only need to provide this information for specified time periods. You should tell us in what form you want the list (paper copy, electronically, or some other form). You can have one list each year at no cost. You will be charged for any additional lists within the year period.
You Have the Right to Ask for a Restriction. You have the right to ask that we restrict or limit some part of your health information. You can also ask that we limit information about you to a person who is giving you care or paying for care like a family member or friend. For example, you could ask that we not give out information about some treatment you have had or that we not tell certain people specific information in your health information. We are not required to agree to your request unless you personally pay for a service and request that your insurer not be notified. However, when the law requires that we bill your insurer, we must do so. You must be aware that when your request for restriction has not been made prior to submission of the Hospital’s payment request to the third party payor, it may not be possible to facilitate the requested restriction. If you wish to restrict the submission of health information to your third party payer, you should make that request prior to the commencement of treatment. There is a person called a Privacy Officer who is the only one who can agree to your request. We will notify you if the restriction will be applied or not.
How to make a request. If you want to restrict or limit the information in your health information that we give out, you must put your request in writing. Tell us (1) what information you want to limit; (2) whether you want to limit our use of your health information, our giving out your health information, or both; and (3) whom should not receive the health information.
You Have the Right to Ask for Privacy in Communications. You have the right to ask that we communicate with you about your health information only in a certain way or at a certain location. An example would be asking that you only be contacted by us at work or only by mail. To ask for privacy in communications, you must make your request in writing to the Hospital. We will attempt to grant all reasonable requests and although you are not required to give reasons for your request, we may ask you. Be sure to be specific in your request about how and where you wish to be contacted. We may charge you for this privacy request and if you fail to pay, the privacy communication will be stopped.
You have the Right to Receive Notice if Your Health Information was Breached. Not all types of breaches require notice, but if notice is required, we will provide ‘you notice’ that will explain the situation and what steps you can take to protect your privacy.
You Have the Right to a Paper Copy of This Notice. A copy of this notice is available to you at your request and you have a right to a copy of this Notice at any time. Even if you get this Notice over email, you still can get a paper copy of it. You can request a copy from the Hospital or you can go to our website, www.holtonhospital.com, and obtain one there.
HOW WILL WE USE AND GIVE OUT YOUR HEALTH INFORMATION? The Hospital can use and disclose your health information without your permission. The following is a list of when we can do this:
For Contact Information We may use and disclose your contact information (landline or cell phone numbers, email address). Some examples of how we may use your contact information include appointment reminders and to provide you with notification of other health related benefits and services, all of which are discussed in more detail below. By providing us with your contact information, you give your consent that we may use it. We may contact you by the following means (even if we initiate contact using an automated telephone dialing system (ATDS) and/or an artificial or prerecorded voice):
(1) paging system; (2) cellular telephone service; (3) landline; (4) text message; (5) email message; or (6) facsimile. If you want to limit these communications to a specific telephone number or numbers, you need to request that only a designated number or numbers be used for these purposes. If you inform us that you do not want to receive such communications we will stop sending these communications to you.
For Treatment We may use your health information to provide you with medical treatment or services. We may give your health information to other doctors, nurses, technicians, medical students, or other staff personnel who are involved in taking care of you. For example, a doctor treating you for a broken bone may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for meals. Different departments of the Hospital may share your health information in order to coordinate the different services you need, such as prescriptions, lab work, and x-rays. We also may disclose your health information to treaters outside the Hospital who may be involved in your treatment while you are in the Hospital or after you leave the Hospital.
For Payment We may use and give out your health information about the treatment you receive here in the Hospital so that you or the insurance company or even a third party can be billed. For example, we may give your health insurance company information about your surgery so that your insurance plan will pay us or pay you for the surgery. Sometimes we may have to tell your insurance company before your surgery to get an “ok” from them so that they will cover the surgery.
For Health Care Operations We may use or give out your health information to make sure we are giving you the best care possible. For example, we may use your health information to see how well our staff takes care of you. We may combine your health care information with other individual’s information to decide on additional services we should offer to our patients and to see if new treatments really work. We may also give your health care information out to doctors, nurses, technicians, medical students, and other hospital workers for their review and for their studies. We may also combine information we have with other hospitals to compare and see how we are doing and how we can provide better treatment. We may remove information from your health information so others who look at your health information cannot see your name. This way, we can study information without knowing the individual names. Here are some other reasons we may use and disclose your health care information: to see how well we are doing in helping our patients; to help reduce health care costs; to develop questionnaires and surveys; to help with care management; to make sure we are doing our job well and successfully; to better train people so they can get the skills they need to best perform their special skills; to help insurance companies better serve you in their policy making; to help those that check up on hospitals and ensure that we are doing our job correctly; to help us plan and develop the business part of healthcare including fund-raising and advertising so that we are profitable. For example, if you have surgery we may use your surgery information to see how long you were in the operating room so we can see how to schedule operations better.
Appointment Reminders We may give out your health information to contact you, a relative, or a friend to remind you that you have an appointment at our Hospital. We may leave a message on your answering machine or voice mail system unless you tell us not to.
Treatment Alternatives We may use or give out your health information to let you know about treatments that may be offered to you so you can make good choices about your health care.
Health Related Benefits and Services We may use and give out health information to tell you about health benefits or services that may be of interest to you.
Marketing Under some circumstances, we may use your health information to market hospital services related to your present treatment to you.
Fundraising Activities We may use your health information, including your name, address or other contact information: age, insurance status, gender, date of birth, department of service, treating physician, and outcome information for fundraising purposes. We may contact you to help our Hospital raise money. We may also give out your health information to a foundation so they can help the hospital raise money. For fundraising, we will only give out basic contact information such as name, address, phone number, and the dates you were treated at the Hospital. If you inform us that you do not want to receive fundraising materials we will stop sending fundraising materials to you.
Hospital General Public Disclosure We may give out limited information about you which will be available to the public. While you are here at the Hospital as a patient, the information we give out may be your name, room number in the Hospital, and your general condition (for example, “Fair,” “stable,” etc.) and your religion. All the above information except your religion can be given out to the public who ask for you by name. Your religion may be given to a minister, priest, or rabbi even if they do not ask for you by name. This is so your relatives, friends, and religious persons can visit you in the Hospital. If you do not want this information given out, you must write the Hospital or indicate it by writing this on the admission/consent form.
Individuals Involved in Your Care or Payment for Your Care We may give out health information about you to one of your friends or family members who is in some way involved in your medical care. We may give out your health information to another person who is helping pay for your care. We may tell your family or friends about your condition and that you are in the Hospital. Also, we may give out your health information as part of a disaster relief effort so your family knows about your condition and location. How much of your health information we give out to another person will depend on how much they are involved in your care.
Research Sometimes for special reasons, we may give out your health information to researchers who want to do scientific research about how well certain drugs or treatments work. If a researcher wants to do a study involving you and your information, we will follow steps to make sure research is approved that will benefit all people. The research must be worthwhile. We may give out health information to researchers to help them find the patients they need for their research study. This information we give them will usually not leave the Hospital. If a researcher wants your name, address, and other information about you, we will almost always ask permission from you before they contact you.
As Required by Law Federal, state, and local laws may require us to give out certain kinds of health information. Things like wounds from weapons, abuse, communicable diseases, and neglect are examples of such information and we do not need your permission to give out this information.
To Avoid a Serious Threat to Health or Safety We may use or give out your health information if your health and safety is at risk or in danger. We also will give out your health information if the health of the public or another individual is at risk. If we give this information out, it will be given to someone who may be able to prevent the threat.
Organ and Tissue Donation If you are an organ donor, we may give out your health information to people who deal with organ collection, eye or tissue transplants, or to a donation bank. We give your information to these people to make sure organ or tissue donation or transplants can be made.
Military and Veterans If you are a member of the armed forces, we may give out your health information as required by those military authorities in command. If you are a member of the military of another country, we may release your health information to the authority in command in your country.
Worker’s Compensation If you are involved in an injury that happens while you are at work, we may have to give out your health information so your medical bills can be paid by your employer. This is called worker’s compensation.
Public Health Risks We may give out your health information without your permission if there is a danger to the public’s health. Some general examples of these dangers: to avoid disease, injury or disability; to report births and deaths; to report child abuse and neglect; to report reactions to drugs and other health products; to report a recall of health products or medications; to tell a person they have been exposed to a disease or may get a disease or spread the disease; to tell a government authority if we believe a patient has been abused, neglected, or the victim of violence; to let employers know about a workplace illness or workplace safety; and/or to report trauma injury to the state. We may also, with consent, give immunization information to a school.
Health Oversight Activities We may give out your health information without your permission to a special group who checks up on hospitals to make sure they are following the rules. These special groups investigate, inspect, and license hospitals. This is necessary for our government to know about our hospitals and that they are following the rules and the laws.
Lawsuits and Disputes We may give out your health information if you are involved in a lawsuit or dispute. If a court orders that we give out your health information even if you are not involved in a lawsuit or dispute, we may also give out your health information. Other reasons that may cause us to release your health information would be if there is an order to appear in court, a discovery request, or other legal reason by someone else involved in a dispute. There must be an effort made to tell you about this request or an order to make sure that the information they want is protected.
Law Enforcement We may give out your health information if asked for by a police official for the following reasons: for a court order, subpoena, warrant, or summons; to find a suspect, fugitive, witness, or missing person; to find out about the victim of a crime if we cannot get the person’s okay; about a death we believe may be the result of a crime; about some crime that happens at the Hospital; in emergencies to report a crime, the place where the crime happened, the victim of the crime, or the identity, description or whereabouts of the person who committed the crime.
Coroners, Medical Examiners and Funeral Directors We may give out your health information to a coroner or medical examiner to identify a person who has died or determine the cause of death. We may also give out health information to funeral directors so they can carry out their duties.
National Security and Intelligence Activities We may give out your health information to federal authorities for intelligence, counter-intelligence, and other situations involving our national safety.
Protective Services for the President and Others We may give out health information about you to federal officials so they can protect the President or other officials or foreign heads of state or so they may conduct special investigations.
Inmates If you are an inmate of a prison or placed under the charge of a law enforcement official, we may give out your health information (1) to the prison to provide you with health care; (2) to protect the health and safety of you and others; or (3) for the safety of the prison.
Redisclosure When we use or give out your health information, it may contain information we received from other hospitals and doctors.
GIVING PERMISSION AND REVOKING PREVIOUS PERMISSION TO USE OR DISCLOSE YOUR HEALTH INFORMATION: Except as stated in this Notice, in order for us to give out your information, you have to complete a written authorization form. If you want, you can later choose not to let us give out your health information. You can do this at any time. Your request to later stop permission to give out your health information must be in writing and sent to the Hospital. It is not possible for us to take back any information we have already given out about you that we made with your permission.
WHAT SHOULD YOU DO IF YOU HAVE A COMPLAINT CONCERNING YOUR HEALTH INFORMATION? If you believe your right to privacy has been violated, you can write a complaint and give it to the Hospital or the U.S. Department of Health and Human Services. To find out how exactly to file a complaint with either the Hospital or the U.S. Department of Health and Human Services, ask the Hospital.
THERE IS NO PENALTY FOR FILING A COMPLAINT.
IF CHANGES ARE MADE TO THIS NOTICE: We will make a copy of this Notice available to you the first time we treat you and whenever you request it. We have the right to change this Notice at any time without letting people know we are going to change it. We have the right to make the changed Notice apply to health information we already have about you as well as any information we receive in the future. We will post a copy of the newest Notice in the Hospital. You will find the date the Notice takes effect at the top of the first page below the title. You can get a copy of this Notice at any time by contacting the Contact Person listed above. You may get a copy of the current Notice each time you come to the Hospital for treatment.
Understanding Hospital Pricing and Charges
Hospital pricing and charges can be difficult to understand. At Holton Community Hospital, we are committed to helping you understand your hospital charges.
What You Should Know
Hospital charges are the same for all patients, but the patient’s financial responsibility for services provided may vary depending upon payment plans negotiated with individual health insurers as well as reimbursement schedules set forth by public payers such as Medicare and Medicaid. These charges do not include items or services that may be billed separately for physician services, lab, diagnostic services, etc.
A charge is not the same as what you may owe. A charge is an amount billed for a service. A patient’s amount due is based on insurance coverage, copay, and co-insurance. If you are uninsured, you may qualify for financial assistance.