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NOTICE OF PRIVACY PRATICES
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) now requires Community Memorial Hospital to provide you with this notice describing our legal duties and privacy practices concerning your personal health information. In general, when we use or disclose your health information, we are obligated to use or disclose only the least amount of information necessary to achieve the purpose. This notice describes how Community Memorial Hospital employees, providers, and volunteers use protected health information, as is necessary to carry out treatment, payment, or other health care operations. Community Memorial Hospital reserves the right to change the privacy practices described in this notice, in accordance with the law. Changes to our privacy practices would apply to all health information maintained by us. If we change our privacy practices, you may obtain a revised copy of the privacy notice at the reception desk of any of our facilities.

We are able to use your health information without written authorization for the following purposes:

• Treatment. We may use medical information about you to provide medical    treatment or services. For example, a physician may use the information to    determine which treatment option, best addresses your health needs.
• Payment. In order for an insurance company or other health insurer to pay for    your treatment, we must submit a bill that identifies you, your diagnosis, and    the treatment provided to you. As a result, we will pass necessary health    information onto an insurer or other agency to help Community Memorial    Hospital receive payment for your medical bills.
• Health Care Operations. We may need your diagnosis, treatment, and    outcome information in order to improve the quality or cost of care delivered    by us. These quality and cost improvement activities include evaluating the    performance of your physicians, nurses and other health care professionals,    or examining the effectiveness of the treatment provided to you when    compared to other patients in similar situations. In addition, we may want to    use your health information for appointment reminders. We will want to let    you know of other treatments or services we offer that may improve or    benefit your health. We may communicate to you through a mailing about    good health practices, and about health fairs, wellness classes or support    groups that we offer. In order to provide more charity care or otherwise    improve the health of the community, we may want to contact you for fund     raising purposes.
• As required or permitted by law. Sometimes we must report some of your    health information to legal authorities, such as police, court officials, or    government agencies. For example, we may have to report abuse, neglect,    domestic violence or certain physical injuries, or to respond to a court order.
• For public health activities. We may be required to report your health    information to authorities to help prevent or control diseases, injury, or    disability. This may include using your medical record to report certain    diseases, injuries, birth or death information, information of concern to the    Food and Drug Administration, or information related to child abuse or    neglect. For public health activities.
• For health oversight activities. We may disclose your health information to    authorities so they can monitor, investigate, inspect, discipline or license    those who work in the health care system or for government benefit    programs.
• For activities related to death. We may disclose your health information to    coroners, medical examiners and funeral directors so they can carry out their    duties.
• For organ, eye or tissue donation. We may disclose your health information to    entities involved in obtaining, banking or transplanting organs, eyes or tissue    for donation.
• For research. Under certain circumstances, and only after a special approval    process, we may use and disclose your health information to help conduct    research.
• To avoid a serious threat to health or safety. As required by law and    standards of ethical conduct, we may disclose your health information to the    necessary authorities, if we believe, in good faith, that such disclosure is    necessary to prevent or minimize a serious and imminent threat to the    public’s health or safety.
• For military, national security, or incarceration/law enforcement custody. If you    are involved with the military, national security or intelligence activities, or you    are in the custody of law enforcement officials or an inmate in a correctional    institution, we may disclose your health information to the proper authorities    so they may carry out their duties under the law.
• For workers’ compensation. We may disclose your health information to the    appropriate persons in order to comply with the laws related to workers’    compensation.
• Community Memorial Hospital Directory. During the admission process you will    be asked if we can list in our directory your name, location in our facility, your    general health condition (e.g., “stable” or “unstable”), and your religious    affiliation. The information about you contained in our directory will be    disclosed to people who ask for you by name. However, the information about    your religious affiliation will only be disclosed to the clergy. You can tell us    whether you object or agree regarding the use of your health information for    directory purposes.
• To those involved with your care or payment of your care. If such people as    family members, relatives, or friends are helping care for you or helping you    pay your medical bills, you determine if we may disclose relevant health    information about you to those people. The information disclosed may include    your location within our facility, and your general condition. You have the right    to object to such disclosure, unless you are incapacitated or there is an    emergency. In addition, we may disclose your health information to    organizations authorized to handle disaster relief efforts.

When Community Memorial Hospital is required to obtain your authorization to use or disclose your health information:
Except for the situations listed above, any other use or disclosure of your health information requires us to obtain your written authorization. You may withdraw your authorization at any time by submitting your written withdrawal to the Medical Record Department at Community Memorial Hospital.

Your Heath Information Rights
You have several rights with regard to your health information. Specifically, you have the right to:

• Inspect and copy your health information. You have the right to inspect and    obtain a copy of your health information, with few exceptions. For example,    this right does not apply to psychotherapy notes or information compiled for    judicial proceedings. In addition, we may charge you a reasonable fee if you    want a copy of your health information.
• Request to amend your health information. If you believe your health    information is incorrect, you may ask us to amend the information. You will be    asked to make such a request in writing and to give a reason as to why your    health information should be changed. However, if we did not create the    health information that you believe is incorrect, or if we disagree with you and    believe your health information is correct, we may deny your request.
• Request restrictions on certain uses and disclosures. You have the right to    notify us that you want restrictions placed on how your health information is    used or to whom your information is disclosed, even if the restriction affects    your treatment, our payment, or our health care operation activities. You    many want to restrict the health information provided to family or friends    involved in your care or payment of medical bills, or to restrict the health    information provided to authorities involved with disaster relief efforts.
• Receive confidential communication of health information. You have the right    to request alternative means or locations where we may communicate your    health information to you. We will accommodate reasonable requests.
• Receive a report of disclosures of your health information. In some limited    instances, you have the right to request a report of the disclosures of your    health information we have made during the previous six years, but the    request cannot include dates before April 14, 2003. This report must include    the date of each disclosure, who received the disclosed health information, a    brief description of the health information disclosed, and why the disclosure    was made. We must comply with your request for the report within 60 days,    unless you agree to a 30-day extension. We may not charge you for the    report, unless you request such a report more than once per year. Our report    will not include disclosures made to you, disclosures where you signed an    authorization form, or disclosures for purposes of treatment, payment, or    health care operations, information that is part of a limited data set, our    directory, national security, law enforcement/corrections, and certain health    oversight activities.
• Obtain a paper copy of this notice. Upon your request, you may at any time    receive a paper copy of this notice, even if you earlier agreed to receive this    notice electronically. This notice is available on-line at www.cmhospital.org. Or    you may call the Medical Record Department at Community Memorial Hospital    to request a paper copy of this notice.
• File a complaint. If you believe your privacy rights have been violated, you may    file a complaint with us and/or the Secretary of Health and Human Services.    Complaints in no way affect how we care for you. To file a complaint with    either entity, please contact the Community Memorial Hospital Privacy Officer    at 920-846-3444.
If you have any questions or concerns, please contact the Community Memorial Hospital Privacy Officer at 920-846-3444.

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