BLESSING SYSTEM NOTICE OF PRIVACY PRACTICES

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.

This privacy notice will be used by the following Blessing System organizations (“The Blessing System”) including, Blessing Corporate Services, Inc., Blessing Hospital, Blessing Corporate Services, Inc. d/b/a Blessing Physician Services, BlessingCare Corp d/b/a Illini Community Hospital, Illini Health Services, LLC, Denman Services, Inc., and Hannibal Medical Supplies, LLC.

In addition, Blessing Hospital will use this Notice as a joint notice with Cogent Healthcare, Quincy Anesthesia Associates, P.C, SIU School of Medicine physicians practicing at East Adams Clinic, West Central Pathology Specialists, S.C., Tri-State Radiation Oncology, PC and Clinical Radiologists, S.C. Illini Community Hospital will use this Notice as a joint notice with Clinical Radiologists, S.C. Blessing Corporate Services will use this as a joint notice with Quincy Medical Group physicians practicing at the Hamilton/Warsaw and the Palmyra Clinics and with SIU School of Medicine physicians practicing at the Quincy Sports and Occupational Medicine Program.

I understand that the hospital has decided to use a Joint Notice of Privacy Practices and a Joint Acknowledgment Form with independent physicians or physician groups relating to federal and state privacy rights and protections for patients which are further described in this Joint Privacy Notice. Discharge documentation from the Hospital to the ambulatory record will be shared.

I further understand, acknowledge and agree that the use of a Joint Notice and Acknowledgment Form, as part of an organized health care arrangement, rather than the use of separate notices and forms under these laws is being done only for my convenience as a patient and to improve access to the delivery of health care services. Finally, I understand, acknowledge and agree that the physicians are and still remain independent contractors and are not agents, servants or employees of the hospital and are solely responsible for their judgment and conduct in treating or providing professional services to me and for their compliance with state and federal privacy laws. Nothing in this privacy notice is meant to imply, infer or create any agency or employment relationship between the physicians and the hospital, either actual or implied, nor is this privacy notice intended to alter or limit any other consents for treatment or procedures I may sign during the time I am provided care at this facility.