St. Dominic-Jackson Memorial Hospital Notice of Privacy Practices


If you have any questions about this notice, please contact St. Dominic’s Privacy Officer at 601-200-2464.


This notice describes St. Dominic-Jackson Memorial Hospital’s practices and that of: 

  • Any healthcare professional authorized to enter information into your hospital chart such as nurses, therapists, etc.;
  • All departments and units of the hospital;
  • All employees, staff, volunteers, contractors, advanced practice professionals, clinical assistants, medical product personnel and other hospital personnel; and
  • Any physician who is a member of the Hospital Medical Staff and involved in your treatment.
We understand that your health information is personal. We are committed to protecting health 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 information regarding 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 health information created in the doctor’s office or clinic.
This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights and our obligations regarding the use and disclosure of health information.
We are required by law to:
  • Make sure that health information that identifies you is kept private;
  • Give you this notice of our legal duties and privacy practices with respect to health information about you;
  • Notify you following a breach of your protected health information that was unsecured; and
  • Follow the terms of the notice that are currently in effect.

The following categories describe examples of different ways that we may use and disclose health 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, the ways we are permitted to use and disclose information fall within one of the categories. For a more inclusive description of permitted uses, see 45 C.F.R. Part 164.
Health Information Organization (HIO)
We may disclose health information about you to a health information organization (HIO). HIO’s facilitate the exchange of electronic protected health information for the purposes of treatment, payment and healthcare operations purposes between and among several health care providers, such as hospitals, doctors, pharmacies, etc.
We may use health information about you to provide you with medical treatment or services. We may disclose health information about you to physicians, nurses, technicians, medical students or other health care personnel who are involved in taking care of you at the hospital. Information obtained by a nurse, physician or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you.
We may also provide your physician or a subsequent healthcare provider with copies of various hospital reports that should assist him or her in treating you once you are discharged from this hospital.
We may use and disclose health information about you so that payment for treatment and services you receive may be collected from you or a third party. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures and supplies used. This may also include the disclosure of health information to obtain prior authorization for treatment and procedures from your insurance plan.
Healthcare Operations
We may use and disclose health information about you in order to operate the hospital. For example, members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. We may combine the health information we have with health 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 also provide your information to our accountants, attorneys, consultants and others in connection with healthcare operations.
As Required by Federal, State or Local Law, Judicial or Administrative Proceedings or Law Enforcement
We will disclose health information about you when a law requires that we report information to government agencies and law enforcement personnel about victims of abuse, neglect or domestic violence; when dealing with gunshot and other wounds; crimes on the premises; crimes in emergencies; and similar situations, or when ordered in a judicial or administrative hearing.
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. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name unless you object in whole or in part.
Individuals Involved in Your Care or Payment for Your Care
We may release health information about you to a friend or family member or personal representative who is involved in your medical care unless you object in whole or in part. We may also tell your family or friends your condition and that you are in the hospital. In addition, we may disclose health 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.
Business Associates
We work with many companies and consultants to perform a wide variety of functions on our behalf. Examples include physician services in the emergency and radiology department, claims processing administrators and a copy service used when making copies of your health record. St. Dominic makes reasonable efforts to safeguard any information provided to our business associates and requires that the business associates appropriately safeguard your information as well.

Public Health Information

As required by law, we may disclose your health information to public health or legal authorities for public health activities. For example, we report information about births, deaths, and various diseases to government officials in charge of collecting that information, and we provide coroners, medical examiners and funeral directors necessary information relating to an individual’s death.

Health Oversight Activities

We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include accreditations, 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.

Organ and Tissue Donation

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


In certain circumstances, we may disclose your health information in order to conduct medical research.

To Avert a Serious Threat to Health or Safety

We may use and disclose health information about you when necessary to prevent a serious threat to your health or safety or the health or safety of the public or another person. Such disclosure would only be to someone able to help prevent the threat.

Specific Government Functions

We may disclose health information of military personnel and veterans in certain situations. We may also disclose information for national security purposes, such as protecting the President of the United States or conducting intelligence operations.

Workers’ Compensation

We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Appointment Reminders and Health Related Benefits and Services

We may use and disclose health information to provide appointment reminders or give you information about treatment alternatives, or other health care services or benefits we offer.

Correctional Institution

If you are an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.


We may contact you to raise funds for a particular hospital service or project. You have the right to opt out of receiving such communications.


Other uses and disclosures of health information not described in the notice will be made only with your written permission.  We must have a written authorization for most uses and disclosures of psychotherapy notes, for marketing purposes, and for sale of protected health information.  If you give us permission to use or disclose health 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 health information about you for the reasons covered by your written authorization.  Please understand that we are unable to take back any disclosure we have already made with your permission, and that we are required to retain our records of the care that we provided to you.


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

Right to Access

You have the right to inspect and copy health information that may be used to make decisions about your care. You have the right to request a copy of your health information in written or electronic format. 

You may also request that your protected health information be transmitted directly to another person designated by you. This request must be in writing, signed by you, and clearly identify the designated person, and where to send the copy of protected health information.   

Usually, this includes medical and billing records, but does not include for example, psychotherapy notes, information compiled for a civil, criminal or administrative proceeding, or information obtained by the Hospital from another source.

To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to St. Dominic-Jackson Memorial Hospital, Attn.: Health Information Management Department, 969 Lakeland Drive, Jackson, MS 39216. 

There may be a fee for the costs of copying, mailing or other supplies associated with your request.

We reserve the right to deny you access to all or part of your health information in limited circumstances. For example, psychotherapy notes, or information compiled in reasonable anticipation of, or for use in a civil, criminal or administrative action proceeding. If you are denied access to all or part of your protected health information, we will do our best to provide you with access to any other protected health information requested after excluding the protected health information to which we have grounds to deny. St. Dominic will also give you a written denial that describes the basis for the denial and, if applicable, a statement of your review rights and a description of how you can exercise those rights. We will also include information on how to file a complaint with St. Dominic or with the Secretary of Health and Human Services.

Right to Amend

If you feel that health 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, you must submit your request in writing and include reasons that support your requested amendment. 

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 health 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 health information about you to external organizations that is not included in this notice or part of treatment, payment and healthcare operations. St. Dominic will provide your requested accounting within 60 days after receipt of the request or notify you in writing if we are unable to meet that deadline.

To request this list or accounting of disclosures, you must submit your request in writing to St. Dominic-Jackson Memorial Hospital, Attn.: Health Information Management Department, 969 Lakeland Drive, Jackson, MS 39216. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. 

Right to Request Restrictions

You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or healthcare operations. You also have the right to request a limit on health 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. If you would like additional information about your rights on requesting restrictions please contact St. Dominic’s Privacy Officer, at 969 Lakeland Drive, Jackson, MS 39216 or by calling 601-200-2464. We are not required to agree to your request. However, if you request that we restrict the disclosure of your health information to your health plan for the purpose of carrying out payment or health care operations (and not otherwise required by law) and you pay out of pocket for your service in full at the time of service, we agree not to disclose your information to your health plan for that date of service.

To request restrictions, you must make your request in writing to St. Dominic’s Health Information Management Department. 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.

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. We will accommodate all requests for such confidential communication to the best of our abilities.

To request communication in a confidential location or way, you must make your request in writing to our Privacy Officer. 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 request this at any time, even if you have agreed to receive this notice electronically.

You may obtain a copy of this notice at our web site, or by contacting our Privacy Officer at 601-200-2464.


We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health 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. You may also obtain a copy of our most recent notice at our web site,

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 St. Dominic, submit your complaint in writing to St. Dominic-Jackson Memorial Hospital, Privacy Officer, 969 Lakeland Drive, Jackson, MS 39216. All complaints must be submitted to St. Dominic in writing. You will not be penalized for filing a complaint.


Click here to download a printable PDF copy of the notice.