Privacy Policy and Practices

• Notice of Privacy Practices
• Patient Rights and Responsibilities
• Patient's Conditions Report Policy

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW SAN LUIS VALLEY REGIONAL MEDICAL CENTER WILL USE YOUR MEDICAL INFORMATION FOR PURPOSES OF TREATMENT, PAYMENT AND OPERATIONS AND HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

If you have any questions about this notice, please contact:
Terri Salazar, Privacy Officer – 719-587-1390
Leonard Snow, Risk Manager – 719-587-1207

Who Will Follow This Notice
This notice describes our hospital's practices and that of:

• Any health care professional authorized to enter information into your hospital chart.
• All departments and units of the hospital.
• Any member of a volunteer group we allow to help you while you are in the hospital.
• All employees, staff and other hospital personnel.
• SLV Regional Medical Center will follow the terms of this notice.

Our Pledge Regarding Medical Information:
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at the hospital. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the hospital, whether made by hospital personnel or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor's use and disclosure of your medical information created in the doctor's office or clinic.

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

We are required by law to:

• make sure that medical information that identifies you is kept private;
• give you this notice of our legal duties and privacy practices with respect to medical information about you; and
• follow the terms of the notice that is currently in effect.

How We May Use and Disclose Medical Information About You
The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other hospital personnel who are involved in taking care of you at the hospital. For example, a doctor treating you for a broken leg 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 appropriate meals. Different departments of the hospital also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose medical information about you to people outside the hospital who may be involved in your medical care after you leave the hospital, such as family members, clergy or others we use to provide services that are part of your care.

For Payment. We may use and disclose medical information about you so that the treatment and services you receive at the hospital may be billed to 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 the hospital 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 to obtain prior approval or to determine whether your plan will cover the treatment.

For Health Care Operations. We may use and disclose medical information about you for hospital operations. These uses and disclosures are necessary to run the hospital and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many hospital patients to decide what additional services the hospital should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other hospital personnel for review and learning purposes. We may also combine the medical information we have with medical information from other hospitals to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.

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

Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

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

Fundraising Activities. We may use medical information about you to contact you in an effort to raise money for the hospital and its operations. We may disclose medical information to a foundation related to the hospital so that the foundation may contact you in raising money for the hospital. We only would release contact information, such as your name, address and phone number and the dates you received treatment or services at the hospital. If you do not want the hospital to contact you for fundraising efforts, you must notify the Privacy Officer at SLV Regional Medical Center in writing.

Hospital Directory. We may include certain limited information about you in the hospital directory while you are a patient at the hospital. This information may include your name, location in the hospital, your general condition (e.g., fair, stable, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they don't ask for you by name. This is so your family, friends and clergy can visit you in the hospital and generally know how you are doing.

Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition and that you are in the hospital. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients' need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process, but we may, however, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave the hospital. We will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at the hospital.

As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety. We may use and disclose medical 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. Any disclosure, however, would only be to someone able to help prevent the threat.

SPECIAL SITUATIONS

Organ and Tissue Donation. If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans. If you are a member of the armed forces, we may release medical information about you as 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 medical information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following:

• to prevent or control disease, injury or disability;
• to report births and deaths;
• to report child abuse or neglect;
• to report reactions to medications or problems with products;
• to notify people of recalls of products they may be using;
• to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
• to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. We may release medical information if asked to do so by a law enforcement official:

• In response to a court order, subpoena, warrant, summons or similar process;
• To identify or locate a suspect, fugitive, material witness, or missing person;
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
• About a death we believe may be the result of criminal conduct;
• About criminal conduct at the hospital; and
• 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.

Coroners, Medical Examiners and Funeral Directors. We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of the hospital to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical 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 Medical Information About You

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

Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.

To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Privacy Officer, Health Information Management, SLV Regional Medical Center. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the hospital will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the hospital.

To request an amendment, your request must be made in writing and submitted to the Privacy Officer, Health Information Management, SLV Regional Medical Center. In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• Is not part of the medical information kept by or for the hospital;
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete.

Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you.

To request this list or accounting of disclosures, you must submit your request in writing to the Privacy Officer, Health Information Management, SLV Regional Medical Center. Your request must state a time period which may not be longer than 10 years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.
We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

To request restrictions, you must make your request in writing to the Privacy Officer, Health Information Management, SLV Regional Medical Center. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, you must make your request in writing to the Privacy Officer, Health Information Management, SLV Regional Medical Center. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

To obtain a paper copy of this notice, please visit the SLV Regional Medical Center
Information Center.

CHANGES TO THIS NOTICE

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the hospital. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register at or are admitted to the hospital for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.

Complaints. If you believe your privacy rights have been violated, you may file a complaint with the hospital or with the Secretary of the Department of Health and Human Services. To file a complaint with the hospital, contact the Privacy Officer, SLV Regional Medical Center, 719-587-1390. All complaints must be submitted in writing. In most cases you will not be penalized for filing a complaint.

Other Uses of Medical Information. Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

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PATIENT RIGHTS AND RESPONSIBILITIES

As a patient in the San Luis Valley Regional Medical Center, in the State of Colorado, you have the right, consistent with law to:

1. Understand and use these rights. If for any reason you do not understand or you need help, the hospital will provide assistance, including an interpreter when possible. A Spanish version of these rights is available upon request.
2. Receive considerate and respectful treatment free of unnecessary physical or chemical restraint or seclusion unless medically indicated or necessary to prevent harm to yourself or others.
3. To receive care in a clean, safe and secure setting and to be free from all forms of abuse or harassment.
4. Receive care without fear of discrimination as to race, color, religion, sex, age, national origin, disability, sexual orientation, or source of payment.
5. Be informed that the healthcare team may include healthcare professionals in training.
6. Know who is responsible for authorizing and performing your procedures or treatments, including the names, positions, and functions of any hospital staff or physicians involved in your care.
7. Expect reasonable response to your requests and needs for treatment or service, within the hospital’s capacity and applicable laws or regulations.
8. Expect personal privacy and confidential communications of any Protected Health Information (PHI), and to request restriction regarding uses and accounting of disclosures within the limits of the law.
9. Expect to have a specified family member or representative and your physician notified promptly of your admission to the hospital.
10. Review and or amend your medical records without charge, within the limits of the law. You may have this information explained to you if you do not understand it. You may obtain a copy of your medical record for which the hospital can charge a reasonable fee. You cannot be denied a copy solely because you cannot afford to pay.
11. Be informed of any hospital policies and procedures that may affect your treatment.
12. Make healthcare decisions in collaboration with your physician, based on your spiritual, cultural, ethical, or other beliefs, including:
    
    
    1. Acceptance or refusal of treatment, to the extent permitted by law, and the revealing of information regarding medical consequences of refusal of treatment.
    2. Participation in your own care delivery and care planning.
    3. Adequate and appropriate pain management.
    4. Responsibility to provide all information about your past care, illness, and medicine to your physician when he/she is trying to find out the best possible treatment options for you.
    5. Formulation of Advanced Directives (Living Will) and the appointment of a surrogate to make healthcare decisions on your behalf to the extent permitted by law.
    6. Receipt of any information necessary to enable you to make informed consent on treatment decisions that reflect your wishes, to the extent permitted by law. This information shall include the possible risks and benefits of procedures, medications and/or treatments.
    7. Understandable information regarding your condition.
    8. Information necessary to enable you to make a decision for an order not to resuscitate and to appoint a representative to make a decision if you are too ill to do so, to the extent permitted by law.
    9. Information about any research/education projects affecting your care or treatment.
    10. Complete information about your diagnosis, treatment options, potential outcomes and to be informed of the possible medical consequences of refusing treatment.
    11. Knowledge of alternative care options available to you, if applicable, when you no longer need hospital care.
    12. Request, at your expense, a consultation with another physician or specialist.
13. Participate in the consideration of ethical issues that arise during your care (or the participation of the patient’s designated representative).
14. Be assured that your guardian, next of kin, or legally authorized responsible person, shall exercise, to the extent permitted by law, the rights delineated on your behalf if you are adjudicated incompetent in accordance with the law; are found by your physician to be medically incapable of understanding a proposed treatment or procedure; or are unable to communicate your wishes regarding treatment, or, are a minor.
15. Be informed of SLVRMC rules and regulations applicable to your conduct as a patient.
16. Be transferred, at your request, to another physician or institution, providing it is medically permissible and that the other institution will accept the transfer.
17. Participate in all decisions about your treatment and discharge from the hospital. The hospital must provide you with a written discharge plan and written description of how you can appeal your discharge. We encourage you to be involved in your discharge planning and your continuing healthcare requirements following your discharge.
18. Receive complete information and an explanation if SLVRMC requests to transfer you to another facility.
19. Receive an itemized bill and an explanation of all charges.
20. Make known your wishes in regard to anatomical gifts. You may document your wishes in your healthcare proxy or on a donor card, available from the hospital.

Among the hospital’s resources for assurance of considerate, respectful care is the SLVRMC’s Ethics Committee, comprised of representatives from many professions and the community. The Ethics Committee aims to be a source of education, policy review, and consultation for the hospital, physicians, patients, and community on issues of medical ethics and dilemmas. You can contact the committee by speaking to your doctor or nurse, or by calling the following departments:

1. Patient and Family Services, 719-587-1350
2. Quality Improvement, 719-587-1207 Complaints regarding quality of care and services may be made directly to the hospital’s staff or via the hospital’s established grievance mechanism with no fear of compromising your future access to care. You will receive a prompt resolution and written response (when applicable) including an internal grievance process. You also have access to the Colorado Department of Health at (303) 692-2800.

Patient Responsibilities

1. To follow hospital rules and regulations to help ensure your own safety and comfort as well as that of other patients.
2. To be honest about matters that relate to you as a patient.
3. To follow the directions and advice offered by the staff.
4. To know the staff who are caring for you.
5. To report changes in your condition to those responsible for the provision of care and welfare.
6. To be considerate and respectful of the needs of other patients and staff in this hospital including their right to privacy and quiet, and adherence to visiting regulations.
7. To observe the no-smoking, clean-air hospital policy.
8. To provide healthcare insurance information for processing bills and assure that financial obligations are fulfilled as promptly as possible.
9. To follow medical advice and treatment plan recommended by your physician.
10. To notify the Patient and Family Representative if you feel your rights are being violated.

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PATIENT CONDITION REPORTS

Any personal information about your diagnosis, treatment and presence in our facility must come from you or your designated representative. This information is only available to the members of your immediate family whom you designate in writing to receive it.

Purpose
The San Luis Valley Regional Medical Center recognizes the importance and benefits of maintaining a working, cooperative relationship with public media. In accordance with our vision, "making exceptional healthcare personal", our goal is to provide accurate and timely information to the media when requested, while protecting the medical confidentiality that all hospital patients are legally entitled to.

Policy Statement
The San Luis Valley Regional Medical Center's guidelines for working with media relations are based on voluntary participation with The Colorado Code of Cooperation Committee, "Public Information Guidelines for Colorado Hospitals, Physicians and News Media". These guidelines include all hospital employees, medical staff and board members as regards the dissemination of information to the public; particularly the news media (TV, Radio, Newspaper) but includes family members or visitors as well. Media inquiries about patient condition are to be initially directed to the Charge Nurse or Department Director if applicable.

For Emergency Department, Trauma and EMS, calls will be directed to the Director of this department, the physician on duty or the charge nurse (Ext. 1312 or 1240). For in patient information, calls will be directed to Director of Medical/Surgical Services or the charge nurse of the patient’s unit (Ext. 1325 or 1330). In the evenings, the Night Supervisor will take calls at Ext. 1351.

Information about patients may not be released without the patient’s permission, except in cases of public record. (See definitions.)

Media Inquiries for Patient Condition Reports

• Media inquiries for inpatients may be directed to the Charge Nurse on the unit where the patient is located.
• Media inquiries for all Emergency Department visits or Ambulance calls, may be made directly to the charge nurse or physician in the Emergency department 24 hours a day at Ext. 1240.
• All external inquiries must request a condition report by the patient's name. Information regarding the condition and location of the patient may only be released if the inquiry specifically contains or specifies the patient's name.

DEFINITIONS

Public Record

• Cases of “public record” are those reportable to public authorities, such as the police, fire department, or coroner. These commonly include, but are not limited to persons brought to the hospital by authorities; persons under arrest or held under police surveillance, alleged stabbings, poisonings, shootings, automobile injuries, burns, assault, bites and unusual industrial accidents.

Procedure

Condition Report Guidelines
Charge Nurses should keep a record of the most recent information provided for the patient to ensure consistent reports across shifts. Inconsistent reports may imply neglect to patient care and thereby damage the hospital's reputation and credibility.

Only a physician may discuss the patient's diagnosis. The hospital spokesperson may not speculate on how, why or what caused the patient's condition, but may describe that condition. The following are standard terms and definitions used to describe the condition of a patient and must be given by authorized personnel. This includes Administrators, Department Directors, Night Supervisor and Charge Nurses.

Other questions about release information may be directed to:

• Colorado Hospital Association: 758-1630 (hospitals)
• Colorado Medical Society: 779-5455 (physicians)
• Colorado Society of Osteopathic Medicine: 322-1752 (physicians)

Clergy Inquires for Patient Condition Reports
If a request is made by a member of the local clergy the patient condition report may be released provided that the patient is a member of the congregation. Hospital pastoral care volunteers are on 24-hour call and available by contacting Pager Number 852-7600. All clergy or hospital pastoral care providers are obligated to abide by the same code of confidentiality as hospital employees and physicians.

Family Members Inquires for Patient Condition Reports
Patient information will not be released to inquiring family members or friends without the written consent of the patient. If the patient is a minor, or deemed incompetent, a condition report may be released with written consent of a parent or legal guardian.

Inquiries for Patient Condition Report for an Unmarried Pregnant Minor
As a parent, the minor can consent to treatment and release of information for her baby without any involvement from parents or legal guardian. However, a minor cannot consent to her own care and treatment unless she is otherwise emancipated. This also applies to a condition report on any mother under the age of 18 who is not emancipated.

Inquires for Patient Condition Report when case of Public Record
In cases of public record, the following information may be released:

• Patient’s name, city, marital status, age, sex, occupation and employer.
• Exception: No identity or information that could identify the person may be released for sexual assault victims or psychiatric, drug or alcohol abuse patients (Federal Law).
• Name of parent may be given if minor or deemed incompetent.
• Name of accident, e.g. auto, fire, shooting, etc., but no statement of cause.
• General information on nature of injury and condition of patient.

Inquiries for Patient Condition in Cases Other than Public Record
Information about patients should not be released without the patient's permission, except where the release involves a matter of public record (see above). When information has been requested and the patient is conscious and can communicate with the doctor or nurse in charge, the patient should be asked whether he or she will permit information about the illness or condition to be released. If the patient agrees to the release of information, it may be released following the same guidelines as for a case of public record. In the case of minors or deemed incompetent persons, a parent or guardian must give written consent for the release of information.

Inquiries for Patient Condition Report in Cases Involving Public Figures or Hospital Employees
Public figures and employees should be treated in the same manner as other hospital patients.
When newsworthy patients are in serious or critical condition, the hospital should arrange (through the attending physician and with the consent of the patient or immediate family) for frequent release of information to the news media. If the person prefers that the news of his or her illness be handled by a personal spokesperson, the hospital should ensure that information relative to the patient's medical condition is provided by an authorized source.
The patient's discharge should be handled with caution. Publicity at this time can have an adverse effect on the patient's condition.

Nature of Injury
In order to protect the privacy of the patient, the hospital spokesperson may release only limited information about various types of accidents or injuries.

AIDS or HIV-related illness. No information may be released by the hospital. Aggregate statistics may be obtained from local health departments and from the Colorado Department of Public Health and Environment.

Battered Children. The hospital spokesperson may describe the injuries sustained by the child, but may not speculate on the cause of the injuries.

Burns. The hospital spokesperson may state that the patient is burned. The severity, percent of body burned and degree of burns may be released after a physician has made a diagnosis.

Fractures. The hospital spokesperson may provide information on the location of the fracture and may say whether the fracture is simple or compound.

Head Injuries. The hospital spokesperson may state that the injuries are to the head.

Internal Injuries. The hospital spokesperson may state that there are internal injuries. The location of the injuries may be given after a physician has made a diagnosis.

Intoxication or Drug Abuse. The hospital spokesperson may not provide information on the admission or treatment of patients who have alcohol or drug abuse problems. In cases where a patient is brought to the hospital for acute care or trauma services, the spokesperson may describe the condition as provided in this section. The hospital spokesperson may not provide information that the patient was intoxicated, speculate that the patient had abused alcohol or drugs, or characterize the patient as an abuser.

Sexual Assault. The condition of the patient may be given. The hospital spokesperson may not say that the patient has been sexually assaulted, or provide information regarding the nature of the sexual assault or injuries.

Shooting or Stabbing. The hospital spokesperson may provide the number of wounds and their location if these facts have been definitely determined by a physician. No statement may be made as to how the shooting or stabbing occurred.

Suicide or Attempted Suicide. The hospital spokesperson may not provide any statement that there was a suicide or attempted suicide.

Transplant recipients and organ donors. The hospital spokesperson may not release any information that would identify, or help identify, recipients or donors unless the recipient or donor family has consented to disclosure. All releases of information should occur in cooperation with and communication between Colorado Organ Recovery Systems, Inc. and the hospital.

Photographs and Interviews
If a member of the media requests to photograph or interview a patient, a hospital administrator (Chief Nurse Office or Chief Marketing Officer) and Charge Nurse must be notified. The request will then be presented to the patient. The patient will then decide whether they would like to participate. In the case of a minor, consent must be given from a parent or guardian in writing.

If the patient agrees to the request, arrangements will be made for a hospital administrator to accompany the reporter to the patient's room. Media are not permitted to take photographs inside the hospital without being accompanied by a hospital administrator. Reporters are not to contact patients directly by calling the patient's room.

The attending physician's name may be released to the news media except when the physician's specialty would relay inappropriate details as to the nature of the patient's problem.

Media interviews or photographs will not be permitted in the Emergency Room or Intensive Care Units. Reporters must wait until the patient has been either discharged from the Emergency Room or transferred to a regular room.

All media visits should be prearranged with the Chief Nursing Officer or the Chief Marketing Officer. If a member of the media arrives unaccompanied by a hospital administrator, that reporter/photographer must be denied access to a patient's room. Call the appropriate hospital administrator for further instructions.

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