Privacy Practices

This notice describes your rights and choices. Additionally, it 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 notice covers (inpatient/hospital-based) services provided to you by Hampstead Hospital and the members of the Medical Staff.

Protecting your privacy is a priority for us and we are required by both federal and state laws to maintain the privacy of your protected health information.

Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of your responsibilities.

Get a copy of your paper medical record (Hampstead Hospital does not have an electronic medical record at this time).
  • You can ask to see or get a paper copy of your medical record and other health information we have about you. Ask us to help you do this.
  • We will provide a copy or a summary of your health information, usually within 30 days of your request.
  • We may charge a reasonable, cost based free.
Ask us to correct your medical record.
  • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
  • We may decline your request, but we will provide an explanation in writing within 60 days.
Request confidential communication.
  • You can ask us to contact you in a specific way. For example, home or office phone or send mail to adifferent address.
  • We will accommodate any reasonable request.
Get a list of those with whom we have shared your information.
  • You can ask for a list (accounting) of the times we have shared your health information for 6 years prior to the date you ask, who we shared it with, and why.
  • We will include all the disclosures except for those about treatment, payment and health care operations, and certain other disclosures (such as any you asked us to make). We will provide one accounting a year for free, but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Choose someone to act for you.
  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
  • We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you believe your privacy rights have been violated.
  • You can complain if you feel we have violated your rights by contacting us using the information on the last page.
  • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting
  • We will not retaliate against you for filing a complaint.
Ask us to limit what we use or share.
  • You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request and we may decline if it would affect your care.
  • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will accommodate this request unless a law requires us to share that information.
Get a copy of this privacy notice.
  • You can ask for a paper copy of this notice at any time.

Your Choices
For certain health information, you can tell us your choices about what we share.

If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do and we will follow your instructions.

You have both the right and the choice in the way that we use and share information as we:
  • Tell family, close friends or others involved in your care about your condition.
  • Provide disaster relief.
  • Include you in a Hospital directory (patient directory).
  • Provide mental health and substance abuse treatment.
  • Market our services and sell your information (we do not market patients or sell patient information).
  • Get a copy of this notice.
  • Raise funds (we do not fundraise).
If you are not able to tell us your preference, for example you are unconscious; we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety/

Our Uses and Disclosures
How do we typically use or share your health information? We typically use or share your health information in the following ways.

Treat you.
  • We can use your health information and share it with other professionals who are treating you.
Run our organization.
  • We can use and share your health information to run our facility, improve your care and contact you when necessary.
Bill for your services.
  • We can use and share your health information to bill and get payment from health plans or other entities.
Help with public health and safety issues.
  • We can share health information about you for certain situations such as:
    • Preventing disease, helping with product re-calls, reporting adverse reactions to medications.
    • Reporting suspected abuse, neglect or domestic violence.
    • Preventing or reducing a serious threat to anyone’s health or safety.
Work with a medical examiner or funeral director/Respond to organ and tissue donation requests.
  • We can share health information with a coroner, medical examiner or funeral director when an individualdies.
Respond to lawsuits and legal actions.
  • We can share health information about you in response to a court or administrative order or in response to a subpoena.
Do research.
  • We can share your information for health research.
Comply with the law.
  • We will share information about you if state or federal laws require it, including the Department of Health and Human Services if they want to see that we are complying with federal privacy law.
  • Under NH law, the identity of a person tested for the human immunodeficiency virus (“HIV”) may be disclosed in response to a written request only if such person has given written authorization for the disclosure; however; a physician or other health care provider may disclose information pertaining to the identity and test results of a person tested for HIV to other physicians and health care providers directly  involved in the health care of the person when the disclosure is necessary in order to protect the health care of the person tested.
  • Also under NH law, written consent is required for disclosures regarding genetic testing and genetic tesresults, except for disclosures by appropriate professionals within a physician’s medical practice or hospital.
Address workers’ compensation, law enforcement and other government requests.
  • We can use or share health information about you:
    • For workers’ compensation claims.
    • For law enforcement purposes or with a law enforcement official.
    • With health oversight agencies for activities authorized by law.
    • For special government functions such as military, national security and presidential protective services.

Our Responsibilities
We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell uswe can, you may change your mind at any time. Let us know in writing if you change your mind.

Additional Information or New Hampshire Chapter332-I: Medical Records, Patient Information and the Health Information Organization Corporation, or Chapter 560: Rights of Surviving Spouse.

Changes to the Terms of this Notice
We can change the terms of this notice and the changes will apply to all information we have about you. The new notice will be available upon request, in our facility and on our website.
Other Information
Privacy Officer: Telephone: 603-329-5311 x 3226

Special Notice:
  • We never market or sell personal information.
  • We will never share any substance abuse or mental health treatment records without your written permission (except as noted by law).
Effective Date of Notice: 4/14/03
Reviewed and Revised: 9/13, 1/15, 1/18